Provider Demographics
NPI:1912153990
Name:CLARKE, THERESE MARIE (PTA)
Entity Type:Individual
Prefix:MISS
First Name:THERESE
Middle Name:MARIE
Last Name:CLARKE
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 1:1361 RILEY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WHITLEYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38588-7024
Mailing Address - Country:US
Mailing Address - Phone:931-268-1444
Mailing Address - Fax:
Practice Address - Street 1:278 DRY VALLEY RD
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38506-5461
Practice Address - Country:US
Practice Address - Phone:931-537-6524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-11
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000003902225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant