Provider Demographics
NPI:1891244794
Name:CLARK, LINDSEY ALICE (PTA)
Entity Type:Individual
Prefix:
First Name:LINDSEY
Middle Name:ALICE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 DULUTH PL
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-3414
Mailing Address - Country:US
Mailing Address - Phone:612-807-0851
Mailing Address - Fax:
Practice Address - Street 1:2140 DULUTH PL
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-3414
Practice Address - Country:US
Practice Address - Phone:612-807-0851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2559-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant