Provider Demographics
NPI:1265047351
Name:CLARK, TAYLOR (DPT)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3536 GAMAGE DR
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23518-5751
Mailing Address - Country:US
Mailing Address - Phone:757-544-8312
Mailing Address - Fax:
Practice Address - Street 1:1015 W 47TH STREET
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23508
Practice Address - Country:US
Practice Address - Phone:757-683-7041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist