Provider Demographics
NPI:1750528964
Name:CLARK, JUSTIN LIAM (DPT)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LIAM
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MORTIMER PL
Mailing Address - Street 2:
Mailing Address - City:BRONXVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10708-4515
Mailing Address - Country:US
Mailing Address - Phone:862-368-1522
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPITAL PLZ
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3602
Practice Address - Country:US
Practice Address - Phone:203-276-2660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-09
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030397225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist