Provider Demographics
NPI:1427470558
Name:CLARK, GINA (PT, DPT)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:SAFATY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5455 HIGHWAY 35
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOOD PARKDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97041-7744
Mailing Address - Country:US
Mailing Address - Phone:503-504-1445
Mailing Address - Fax:
Practice Address - Street 1:551 LONE PINE BLVD
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-9403
Practice Address - Country:US
Practice Address - Phone:541-296-7202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-08
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60194225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist