Provider Demographics
NPI:1528341807
Name:CLARK, CORRIE QUIN (PTA)
Entity type:Individual
Prefix:
First Name:CORRIE
Middle Name:QUIN
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 1:19500 SANDRIDGE WAY STE 230
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-3689
Mailing Address - Country:US
Mailing Address - Phone:703-724-7272
Mailing Address - Fax:703-724-9232
Practice Address - Street 1:19500 SANDRIDGE WAY STE 230
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-3689
Practice Address - Country:US
Practice Address - Phone:703-724-7272
Practice Address - Fax:703-724-9232
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306603106225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist