Provider Demographics
NPI:1306849955
Name:CLARK, MICHAEL J (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:CLARK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:275 W TIETAN ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4363
Mailing Address - Country:US
Mailing Address - Phone:509-522-0114
Mailing Address - Fax:509-522-9868
Practice Address - Street 1:275 W TIETAN ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4363
Practice Address - Country:US
Practice Address - Phone:509-522-0114
Practice Address - Fax:509-522-9868
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2569225100000X
WAPT00005772225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA650011919OtherRAILROAD MEDICARE
WA0766690001OtherCIGNA GOVERNMENT SERVICES
WA108672OtherLABOR & INDUSTRIES PROVID
WA8348476Medicaid
WACL5823OtherREGENCE BC/BS