Provider Demographics
NPI:1972361376
Name:CLARK, KAITLYN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KAITLYN
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 1:1274 TUROCK DR
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:NY
Mailing Address - Zip Code:14727-9452
Mailing Address - Country:US
Mailing Address - Phone:716-244-8148
Mailing Address - Fax:
Practice Address - Street 1:1994 STATE ROAD 44
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-8349
Practice Address - Country:US
Practice Address - Phone:386-516-8344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051069225100000X
FL41353225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist