Provider Demographics
NPI:1124208319
Name:CLARK, ELSA MARIE (MPT)
Entity type:Individual
Prefix:MS
First Name:ELSA
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:ELSA
Other - Middle Name:
Other - Last Name:CLARK HERNDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-5820
Mailing Address - Fax:
Practice Address - Street 1:220 S COURTENAY PKWY STE B
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-4893
Practice Address - Country:US
Practice Address - Phone:321-434-5820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT7723225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLUJ966OtherMEDICARE HF