Provider Demographics
NPI:1902900293
Name:CLARK, KIMBERLY A (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:621 SPLIT ROCK RD
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:VT
Mailing Address - Zip Code:05472-2106
Mailing Address - Country:US
Mailing Address - Phone:802-877-9929
Mailing Address - Fax:
Practice Address - Street 1:614 MONKTON RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VT
Practice Address - Zip Code:05443-5392
Practice Address - Country:US
Practice Address - Phone:802-349-1808
Practice Address - Fax:802-453-2988
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-08
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0002918225100000X
VT0400002918225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT6702477Medicaid