Provider Demographics
NPI:1932663499
Name:EDWARDS, CLARK (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1989 CAPITAL CIR NE STE 9
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4476
Mailing Address - Country:US
Mailing Address - Phone:504-029-7768
Mailing Address - Fax:850-765-6422
Practice Address - Street 1:1989 CAPITAL CIR NE STE 9
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4476
Practice Address - Country:US
Practice Address - Phone:504-029-7768
Practice Address - Fax:850-765-6422
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18776225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist