Provider Demographics
NPI:1669787107
Name:CLARK, ASHLEY E (PT)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:E
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 1:3463 HIGHWAY 21 STE 112
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-7210
Mailing Address - Country:US
Mailing Address - Phone:704-900-3674
Mailing Address - Fax:
Practice Address - Street 1:3463 HIGHWAY 21 STE 112
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-7210
Practice Address - Country:US
Practice Address - Phone:704-900-3674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2024-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11423225100000X
NC12733225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist