Provider Demographics
NPI:1851538334
Name:CLARK, AMY SUE (PTDPT, CMT)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:SUE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PTDPT, CMT
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:SUE
Other - Last Name:HUNTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTDPTCMT
Mailing Address - Street 1:1515 VILLAGE DR.
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424
Mailing Address - Country:US
Mailing Address - Phone:541-767-5260
Mailing Address - Fax:541-767-2566
Practice Address - Street 1:4525 WEAVER PKWY
Practice Address - Street 2:SUITE 310
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-0318
Practice Address - Country:US
Practice Address - Phone:917-428-0193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305205786225100000X
TX1179646225100000X
NY62 028723225100000X
AK1964225100000X
OR06952225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist