Provider Demographics
NPI:1851691489
Name:CLARKSTON, CODY BRET (DPT)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:BRET
Last Name:CLARKSTON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 PRINCETON TER
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07436-3507
Mailing Address - Country:US
Mailing Address - Phone:973-885-3893
Mailing Address - Fax:
Practice Address - Street 1:381 STATE RT 23
Practice Address - Street 2:
Practice Address - City:POMPTON PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07444-1812
Practice Address - Country:US
Practice Address - Phone:973-885-3893
Practice Address - Fax:201-581-0218
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-29
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01316500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist