Basic Information
| Provider Information | |||||||||
| NPI: | 1104395706 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | ISABEAU | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1065 TUCKDA WAY | ||||||||
| Address2: | |||||||||
| City: | HAMPTONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270208291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889131910 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10000 W 75TH ST STE 250 | ||||||||
| Address2: | |||||||||
| City: | MERRIAM | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662042218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889131910 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2018 | ||||||||
| LastUpdateDate: | 11/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | A6586 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.