Provider Demographics
NPI:1821582495
Name:CLARK, AUTUMN F (DPT,PT)
Entity Type:Individual
Prefix:DR
First Name:AUTUMN
Middle Name:F
Last Name:CLARK
Suffix:
Gender:F
Credentials:DPT,PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2182 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:FT MITCHELL
Mailing Address - State:KY
Mailing Address - Zip Code:41017-2902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2182 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:FT MITCHELL
Practice Address - State:KY
Practice Address - Zip Code:41017-2902
Practice Address - Country:US
Practice Address - Phone:859-344-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY006863225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist