Provider Demographics
NPI:1902233083
Name:CLARK, ALYSSA NANETTE (LMT)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:NANETTE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 TALLOW LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214-5553
Mailing Address - Country:US
Mailing Address - Phone:812-786-3169
Mailing Address - Fax:
Practice Address - Street 1:140 N 4TH ST
Practice Address - Street 2:EAST TOWER 17TH FLOOR
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-4227
Practice Address - Country:US
Practice Address - Phone:502-587-7644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-4831225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist