Provider Demographics
NPI:1881275436
Name:CLARK, MLEE R (LMT, CLT)
Entity type:Individual
Prefix:
First Name:MLEE
Middle Name:R
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 E BUNKER HILL DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-1079
Mailing Address - Country:US
Mailing Address - Phone:480-459-8164
Mailing Address - Fax:
Practice Address - Street 1:614 E BUNKER HILL DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-1079
Practice Address - Country:US
Practice Address - Phone:480-459-8164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist