Provider Demographics
NPI:1063914109
Name:CLARK, MICHELLE B
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:B
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:M
Other - Last Name:BERCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8200 DODGE ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-4113
Mailing Address - Country:US
Mailing Address - Phone:402-955-5400
Mailing Address - Fax:
Practice Address - Street 1:17809 PIERCE PLZ
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-1035
Practice Address - Country:US
Practice Address - Phone:402-955-8355
Practice Address - Fax:402-955-8356
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE36522251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics