Provider Demographics
NPI:1811107030
Name:CLARK, KATHY (PTA)
Entity type:Individual
Prefix:
First Name:KATHY
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 1:12800 BIRCHWOOD PIKE
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:TN
Mailing Address - Zip Code:37341-8903
Mailing Address - Country:US
Mailing Address - Phone:423-961-0489
Mailing Address - Fax:
Practice Address - Street 1:1 SISKIN PLZ
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-1306
Practice Address - Country:US
Practice Address - Phone:423-634-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000057225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant