Provider Demographics
NPI:1982890414
Name:CLARK, CARLA MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:CARLA
Other - Middle Name:MARIE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:709 W CHANNEL ISLANDS BLVD
Mailing Address - Street 2:SUITE 157
Mailing Address - City:PORT HUENEME
Mailing Address - State:CA
Mailing Address - Zip Code:93041-2130
Mailing Address - Country:US
Mailing Address - Phone:805-382-6245
Mailing Address - Fax:805-382-6245
Practice Address - Street 1:709 W CHANNEL ISLANDS BLVD
Practice Address - Street 2:SUITE 157
Practice Address - City:PORT HUENEME
Practice Address - State:CA
Practice Address - Zip Code:93041-2130
Practice Address - Country:US
Practice Address - Phone:805-382-6245
Practice Address - Fax:805-382-6245
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 6660225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant