Provider Demographics
NPI:1902075914
Name:CLAY PHYSICAL THERAPY PA
Entity Type:Organization
Organization Name:CLAY PHYSICAL THERAPY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:VALLONE
Authorized Official - Last Name:SHIMKO
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:904-269-7751
Mailing Address - Street 1:PO BOX 505
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32067-0505
Mailing Address - Country:US
Mailing Address - Phone:904-269-7751
Mailing Address - Fax:904-278-8552
Practice Address - Street 1:1626 SHEFFIELD PL
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5268
Practice Address - Country:US
Practice Address - Phone:904-269-7751
Practice Address - Fax:904-278-8552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-23
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0014414225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL678795996OtherMEDWAIVER
FL885134400Medicaid
FLE1907AOtherMEDICARE INDIVIDUAL
FLE1907AOtherMEDICARE INDIVIDUAL