Provider Demographics
NPI:1720178650
Name:CLARK, DEBRA SUE (PT)
Entity type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:SUE
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 1:3500 S BOULEVARD
Mailing Address - Street 2:STE A1
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5490
Mailing Address - Country:US
Mailing Address - Phone:405-513-8118
Mailing Address - Fax:405-513-6490
Practice Address - Street 1:3500 S BOULEVARD
Practice Address - Street 2:SUITE A
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5490
Practice Address - Country:US
Practice Address - Phone:405-513-8118
Practice Address - Fax:405-513-6490
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT 8212251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic