Provider Demographics
NPI:1295994234
Name:CLARK, DARLENE KIM (PT)
Entity type:Individual
Prefix:MRS
First Name:DARLENE
Middle Name:KIM
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 170-2
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:WV
Mailing Address - Zip Code:26253-9748
Mailing Address - Country:US
Mailing Address - Phone:304-636-8157
Mailing Address - Fax:
Practice Address - Street 1:108 3RD ST STE 26
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3831
Practice Address - Country:US
Practice Address - Phone:304-636-4070
Practice Address - Fax:304-636-4070
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV993225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7301118000Medicaid