Provider Demographics
NPI:1912929720
Name:CLARK, MARK ALLEN (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLEN
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 ARROWSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-9600
Mailing Address - Country:US
Mailing Address - Phone:502-222-2615
Mailing Address - Fax:502-222-2617
Practice Address - Street 1:5201 ARROWSHIRE DR
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-9600
Practice Address - Country:US
Practice Address - Phone:502-222-2615
Practice Address - Fax:502-222-2617
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2022-05-31
Deactivation Date:2022-05-17
Deactivation Code:
Reactivation Date:2022-05-31
Provider Licenses
StateLicense IDTaxonomies
KY001751225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist