Provider Demographics
NPI:1386911212
Name:CLARK, RACHEL LYNN (PTA)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2312 PARKMEADOW DR
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-2391
Mailing Address - Country:US
Mailing Address - Phone:608-289-1872
Mailing Address - Fax:
Practice Address - Street 1:2121 PIONEER DR
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-3025
Practice Address - Country:US
Practice Address - Phone:608-365-9526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI907-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant