Provider Demographics
NPI:1336914456
Name:CLARK, TRACY LYNN (LPTA)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27794 REEL RD
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63383-1941
Mailing Address - Country:US
Mailing Address - Phone:314-267-4364
Mailing Address - Fax:
Practice Address - Street 1:27794 REEL RD
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:MO
Practice Address - Zip Code:63383-1941
Practice Address - Country:US
Practice Address - Phone:314-267-4364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117465225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant