Provider Demographics
NPI:1821150012
Name:HEATH, CLARK D (PT)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:D
Last Name:HEATH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:7201 W CLEARWATER AVE
Mailing Address - Street 2:SUITE B101
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-1694
Mailing Address - Country:US
Mailing Address - Phone:509-544-0265
Mailing Address - Fax:509-987-1614
Practice Address - Street 1:343 WELLSIAN WAY
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-4116
Practice Address - Country:US
Practice Address - Phone:509-946-9191
Practice Address - Fax:509-946-8247
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAPT00006264225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8335150Medicaid
WA0195235OtherLABOR & INDUSTRIES
WAGAB12121Medicare PIN