Provider Demographics
NPI:1699255570
Name:CLARK, CAITLIN JADE (PTA)
Entity type:Individual
Prefix:MRS
First Name:CAITLIN
Middle Name:JADE
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 1:301 WOOD BRIDGE
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904
Mailing Address - Country:US
Mailing Address - Phone:361-649-5979
Mailing Address - Fax:
Practice Address - Street 1:225 E WARD ST
Practice Address - Street 2:
Practice Address - City:GOLIAD
Practice Address - State:TX
Practice Address - Zip Code:77963-4006
Practice Address - Country:US
Practice Address - Phone:361-645-8902
Practice Address - Fax:361-645-8689
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2096023225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant