Provider Demographics
NPI:1154990133
Name:CLARK, MARIAH LEYNA (LAT, ATC)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:LEYNA
Last Name:CLARK
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:MARIAH
Other - Middle Name:LEYNA
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:14 SNELL DR
Mailing Address - Street 2:
Mailing Address - City:LAMPASAS
Mailing Address - State:TX
Mailing Address - Zip Code:76550-3621
Mailing Address - Country:US
Mailing Address - Phone:254-258-3863
Mailing Address - Fax:
Practice Address - Street 1:2000 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-4200
Practice Address - Country:US
Practice Address - Phone:717-975-4790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT82122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer