Provider Demographics
NPI:1124320692
Name:CLARK, WILLIAM WARREN (CTRS)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:WARREN
Last Name:CLARK
Suffix:
Gender:M
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 STAGECOACH TRL
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-3224
Mailing Address - Country:US
Mailing Address - Phone:254-931-9531
Mailing Address - Fax:
Practice Address - Street 1:2118 STAGECOACH TRL
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-3224
Practice Address - Country:US
Practice Address - Phone:254-931-9531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-03
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist