Provider Demographics
NPI:1427672740
Name:BILBREY, CLARK TANNER (PT, DPT, ATC)
Entity type:Individual
Prefix:DR
First Name:CLARK
Middle Name:TANNER
Last Name:BILBREY
Suffix:
Gender:M
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 W 300 S
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-9629
Mailing Address - Country:US
Mailing Address - Phone:615-290-2737
Mailing Address - Fax:
Practice Address - Street 1:3691 WILLOWCREEK RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5080
Practice Address - Country:US
Practice Address - Phone:219-921-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36003318A2255A2300X
IN05013728A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN05013728AOtherINDIANA PROFESSIONAL LICENSING AGENCY
IN36003318AOtherINDIANA PROFESSIONAL LICENSING AGENCY