Provider Demographics
NPI:1992357438
Name:CLARK, LIAM CONOR
Entity Type:Individual
Prefix:
First Name:LIAM
Middle Name:CONOR
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N JOHN R WOODEN DR
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47907-2117
Mailing Address - Country:US
Mailing Address - Phone:765-494-3245
Mailing Address - Fax:765-494-9899
Practice Address - Street 1:900 N JOHN R WOODEN DR
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47907-2117
Practice Address - Country:US
Practice Address - Phone:765-494-3245
Practice Address - Fax:765-494-9899
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer