Provider Demographics
NPI:1023141694
Name:CLARKE, LISA ARDELLE (PTA)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:ARDELLE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:ARDELLE
Other - Last Name:CLARKE-BARNES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:2400 PORTRUSH DR
Mailing Address - Street 2:APT 8
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-3334
Mailing Address - Country:US
Mailing Address - Phone:864-285-4540
Mailing Address - Fax:
Practice Address - Street 1:2400 PORTRUSH DR
Practice Address - Street 2:APT 8
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-3334
Practice Address - Country:US
Practice Address - Phone:864-285-4540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1803225200000X
VA1650225200000X
NC1240225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant