Provider Demographics
NPI:1619704178
Name:CLARK, CHANDLER (PTA)
Entity type:Individual
Prefix:
First Name:CHANDLER
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 HOLLYTREE DR APT 3002
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3486
Mailing Address - Country:US
Mailing Address - Phone:903-520-0593
Mailing Address - Fax:
Practice Address - Street 1:3100 OLYMPUS BLVD STE 500
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-5473
Practice Address - Country:US
Practice Address - Phone:214-442-4329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2182964225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant