Provider Demographics
NPI:1841203304
Name:LIPKE, CLYDE NEAL (PT)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:NEAL
Last Name:LIPKE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 S SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:WOODBINE
Mailing Address - State:NJ
Mailing Address - Zip Code:08270-9642
Mailing Address - Country:US
Mailing Address - Phone:609-886-1551
Mailing Address - Fax:609-886-5608
Practice Address - Street 1:1121 ROUTE 47 S
Practice Address - Street 2:
Practice Address - City:RIO GRANDE
Practice Address - State:NJ
Practice Address - Zip Code:08242-1600
Practice Address - Country:US
Practice Address - Phone:609-886-1551
Practice Address - Fax:609-886-5608
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00384700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJLI524240Medicare ID - Type Unspecified