Provider Demographics
NPI:1699750778
Name:CLARK, MICHELLE RENEE (PT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40680 CALIFORNIA OAKS RD
Mailing Address - Street 2:STE 2A
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5755
Mailing Address - Country:US
Mailing Address - Phone:951-894-4800
Mailing Address - Fax:951-894-4804
Practice Address - Street 1:25285 MADISON AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-8955
Practice Address - Country:US
Practice Address - Phone:951-600-2990
Practice Address - Fax:951-600-7224
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2020-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT14472225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT144721Medicare ID - Type Unspecified