Provider Demographics
NPI:1023484318
Name:CLARK, HEATHER (PT, DPT)
Entity type:Individual
Prefix:
First Name:HEATHER
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 1:1560 S CAROL ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1839
Mailing Address - Country:US
Mailing Address - Phone:208-288-1155
Mailing Address - Fax:208-288-0424
Practice Address - Street 1:10790 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1329
Practice Address - Country:US
Practice Address - Phone:208-322-8709
Practice Address - Fax:208-322-8710
Is Sole Proprietor?:No
Enumeration Date:2015-08-20
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-4128225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPT-4128OtherIDAHO STATE LICENSE