Provider Demographics
NPI:1770599292
Name:CLARK, STACIE (MPT)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3449 HADLEY RD
Mailing Address - Street 2:
Mailing Address - City:HADLEY
Mailing Address - State:PA
Mailing Address - Zip Code:16130-2821
Mailing Address - Country:US
Mailing Address - Phone:724-253-1044
Mailing Address - Fax:
Practice Address - Street 1:2447 MERCER ST
Practice Address - Street 2:
Practice Address - City:STONEBORO
Practice Address - State:PA
Practice Address - Zip Code:16153-2711
Practice Address - Country:US
Practice Address - Phone:724-376-3666
Practice Address - Fax:724-376-2460
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT06825225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist