Provider Demographics
NPI:1538739172
Name:CLARK, MICHAEL ANTHONY (LMT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:CLARK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 201911
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78220-8911
Mailing Address - Country:US
Mailing Address - Phone:757-968-0264
Mailing Address - Fax:
Practice Address - Street 1:2510 NACOGDOCHES RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-6025
Practice Address - Country:US
Practice Address - Phone:210-829-8830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-27
Last Update Date:2021-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT134239225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist