Provider Demographics
NPI:1881705622
Name:CLARK, PHYLLIS J (PT)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:J
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 CHAMBERLAIN CIR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75023-5401
Mailing Address - Country:US
Mailing Address - Phone:972-596-0886
Mailing Address - Fax:
Practice Address - Street 1:2801 REGAL RD
Practice Address - Street 2:SUITE 109
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-6315
Practice Address - Country:US
Practice Address - Phone:972-985-2311
Practice Address - Fax:972-985-8711
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1094233225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX659542OtherBCBS PROVIDER NUMBER
TX650547Medicare ID - Type UnspecifiedPART B PROVIDER NUMBER