Provider Demographics
NPI:1215275177
Name:ROSS, CLINT MATTHEW (PTA)
Entity type:Individual
Prefix:
First Name:CLINT
Middle Name:MATTHEW
Last Name:ROSS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 WILSON SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TN
Mailing Address - Zip Code:38340-3767
Mailing Address - Country:US
Mailing Address - Phone:731-435-0135
Mailing Address - Fax:
Practice Address - Street 1:200 BIRCH ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-6684
Practice Address - Country:US
Practice Address - Phone:731-422-5641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-27
Last Update Date:2013-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000005298225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant