Provider Demographics
NPI:1013227289
Name:CLARK, LINNETTE ANN (PT, PHD)
Entity Type:Individual
Prefix:
First Name:LINNETTE
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 INGRAHAM #202
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109
Mailing Address - Country:US
Mailing Address - Phone:925-963-6753
Mailing Address - Fax:
Practice Address - Street 1:4647 ZION AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-2507
Practice Address - Country:US
Practice Address - Phone:619-528-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9523225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist