Provider Demographics
NPI:1700644051
Name:CLARK, KELLI (DPT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7632 PINESPRINGS WEST DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-4021
Mailing Address - Country:US
Mailing Address - Phone:317-250-0375
Mailing Address - Fax:
Practice Address - Street 1:7632 PINESPRINGS WEST DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-4021
Practice Address - Country:US
Practice Address - Phone:317-250-0375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05011329A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist