Provider Demographics
NPI:1215057708
Name:CLARK, SUSAN M (LMT, MMT)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMT, MMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 E HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-2443
Mailing Address - Country:US
Mailing Address - Phone:516-817-5083
Mailing Address - Fax:
Practice Address - Street 1:714 E PARK AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-2605
Practice Address - Country:US
Practice Address - Phone:516-431-7972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013274225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist