Provider Demographics
NPI:1528614153
Name:CLARK, KELLY ANN (DPT, PT, MT)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:DPT, PT, MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 N WALNUT ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-2008
Mailing Address - Country:US
Mailing Address - Phone:812-558-0708
Mailing Address - Fax:
Practice Address - Street 1:2620 N WALNUT ST
Practice Address - Street 2:SUITE 600
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-2008
Practice Address - Country:US
Practice Address - Phone:812-558-0708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21304740225700000X
IN05013530A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty