Provider Demographics
NPI:1265868368
Name:CLARK, VANESSA YOUNG (PT)
Entity type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:YOUNG
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:VANESSA
Other - Middle Name:FAYE
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:12047 LAKE ESTATES AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-7323
Mailing Address - Country:US
Mailing Address - Phone:225-761-0828
Mailing Address - Fax:
Practice Address - Street 1:12047 LAKE ESTATES AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-7323
Practice Address - Country:US
Practice Address - Phone:225-761-0828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-20
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA03158225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist