Provider Demographics
NPI:1164975439
Name:CLARK, CHRISTINA
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4729 SYMPHONY DR
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-4118
Mailing Address - Country:US
Mailing Address - Phone:541-357-3839
Mailing Address - Fax:
Practice Address - Street 1:260 W BROADWAY
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3037
Practice Address - Country:US
Practice Address - Phone:541-357-3839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31800225100000X
WA60837923225100000X
OR65043225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist