Provider Demographics
NPI:1336486026
Name:CLARK, STEPHANIE (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LONDONDERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03053-3691
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 PARK AVE
Practice Address - Street 2:
Practice Address - City:LONDONDERRY
Practice Address - State:NH
Practice Address - Zip Code:03053-3691
Practice Address - Country:US
Practice Address - Phone:603-247-0474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL32542255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer