Provider Demographics
NPI:1396894267
Name:CLARKE, RUSSELL LIONEL (PT, CHT)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:LIONEL
Last Name:CLARKE
Suffix:
Gender:M
Credentials:PT, CHT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9720 S 1300 E
Mailing Address - Street 2:W200
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3712
Mailing Address - Country:US
Mailing Address - Phone:801-572-0690
Mailing Address - Fax:801-572-0696
Practice Address - Street 1:1577 W 7000 S
Practice Address - Street 2:100
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-7492
Practice Address - Country:US
Practice Address - Phone:801-566-6301
Practice Address - Fax:801-566-4739
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT279763-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT279763-2401OtherLICENSE NUMBER