Provider Demographics
NPI:1538447560
Name:CLARK, STEPHANIE RENAE (PT, DPT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RENAE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 PILOT HOUSE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1990
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:927 BATTLEFIELD BLVD N
Practice Address - Street 2:SUITE 200
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4853
Practice Address - Country:US
Practice Address - Phone:757-436-3350
Practice Address - Fax:757-547-9367
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207045225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9400791OtherAETNA
VA1538447560Medicaid
VAC05954Medicare PIN
VA9400791OtherAETNA