Provider Demographics
NPI:1770152613
Name:CLARK, KAYCIE (PTA)
Entity type:Individual
Prefix:
First Name:KAYCIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 CADOGAN WAY
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03062-2255
Mailing Address - Country:US
Mailing Address - Phone:207-841-2982
Mailing Address - Fax:
Practice Address - Street 1:91A N STATE ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-4334
Practice Address - Country:US
Practice Address - Phone:603-724-2297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1253225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant