Provider Demographics
NPI:1922508613
Name:CLARK, ELIZABETH (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 N BUCHANAN ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-3208
Mailing Address - Country:US
Mailing Address - Phone:724-355-8907
Mailing Address - Fax:
Practice Address - Street 1:1306 MILITARY RD STE 1
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-2732
Practice Address - Country:US
Practice Address - Phone:501-481-8930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-19
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28857225100000X
PAPT027442225100000X
ARPT4428225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist