Provider Demographics
NPI:1942637012
Name:CLARK, ALISHA SHAVON (PT)
Entity Type:Individual
Prefix:
First Name:ALISHA
Middle Name:SHAVON
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 HIGHWAY 51 N
Mailing Address - Street 2:BLDG 17, APT. 208
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-7940
Mailing Address - Country:US
Mailing Address - Phone:901-238-1624
Mailing Address - Fax:
Practice Address - Street 1:4740 HIGHWAY 51 N
Practice Address - Street 2:BLDG 17, APT. 208
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-7940
Practice Address - Country:US
Practice Address - Phone:901-238-1624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4135225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics