Provider Demographics
NPI:1851644165
Name:CLARK, MICHELLE J (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:J
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:860 OMNI BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4430
Mailing Address - Country:US
Mailing Address - Phone:757-232-8769
Mailing Address - Fax:757-232-8855
Practice Address - Street 1:5424 DISCOVERY PARK BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2904
Practice Address - Country:US
Practice Address - Phone:757-345-2512
Practice Address - Fax:757-345-0859
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA2305204753225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist