Provider Demographics
NPI:1992413785
Name:CLARK, BECKY (LAT/ATC)
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LAT/ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 HOBBY CIR
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37110-6336
Mailing Address - Country:US
Mailing Address - Phone:931-273-6310
Mailing Address - Fax:
Practice Address - Street 1:3087 SPARTA ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-1364
Practice Address - Country:US
Practice Address - Phone:931-815-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer