Provider Demographics
NPI:1013451095
Name:CLARK, JOSHUA (NSCA-CPT)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:NSCA-CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4149
Mailing Address - Country:US
Mailing Address - Phone:774-279-1044
Mailing Address - Fax:
Practice Address - Street 1:170 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-4149
Practice Address - Country:US
Practice Address - Phone:774-279-1044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-11
Last Update Date:2016-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS622362082255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer