Provider Demographics
NPI:1073377677
Name:CLARKE, AUDREY (PT, DPT)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3607 MENCHACA RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-5947
Mailing Address - Country:US
Mailing Address - Phone:512-444-7219
Mailing Address - Fax:512-982-4331
Practice Address - Street 1:3607 MENCHACA RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-5947
Practice Address - Country:US
Practice Address - Phone:512-444-7219
Practice Address - Fax:512-982-4331
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251P0200X
TX13894342251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics