Provider Demographics
NPI:1538538350
Name:CLARK, HEATHER LACEY (DPT)
Entity type:Individual
Prefix:MISS
First Name:HEATHER
Middle Name:LACEY
Last Name:CLARK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LACEY
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:703 E MAIN ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-8696
Mailing Address - Country:US
Mailing Address - Phone:270-699-9503
Mailing Address - Fax:270-699-3804
Practice Address - Street 1:703 E MAIN ST UNIT 1
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-8696
Practice Address - Country:US
Practice Address - Phone:270-699-9503
Practice Address - Fax:270-699-3804
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY006757225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY18-6639Medicare PIN