Provider Demographics
NPI:1932548757
Name:CLARK, SUZANA IRENE (PTA)
Entity Type:Individual
Prefix:MS
First Name:SUZANA
Middle Name:IRENE
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 1:100 ANTRIM BLVD
Mailing Address - Street 2:
Mailing Address - City:TANEYTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21787-2277
Mailing Address - Country:US
Mailing Address - Phone:410-756-6400
Mailing Address - Fax:410-756-5173
Practice Address - Street 1:100 ANTRIM BLVD
Practice Address - Street 2:
Practice Address - City:TANEYTOWN
Practice Address - State:MD
Practice Address - Zip Code:21787-2277
Practice Address - Country:US
Practice Address - Phone:410-756-6400
Practice Address - Fax:410-756-5173
Is Sole Proprietor?:No
Enumeration Date:2013-06-15
Last Update Date:2013-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA2412174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist