Basic Information
Provider Information | |||||||||
NPI: | 1174830111 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCLARY | ||||||||
FirstName: | KAREN | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2404 S. LOCUST ST | ||||||||
Address2: | STE 5 | ||||||||
City: | LAS CRUCES | ||||||||
State: | NM | ||||||||
PostalCode: | 880015789 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5755214188 | ||||||||
FaxNumber: | 5755213668 | ||||||||
Practice Location | |||||||||
Address1: | 2205 S MAIN ST | ||||||||
Address2: |   | ||||||||
City: | LAS CRUCES | ||||||||
State: | NM | ||||||||
PostalCode: | 880053113 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5756523515 | ||||||||
FaxNumber: | 5756523518 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2010 | ||||||||
LastUpdateDate: | 10/26/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT60185600 | WA | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225100000X | 4149 | NM | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 03339MC | 01 | WA | REGENCE | OTHER | 0333MC | 01 | WA | REGENCE | OTHER | 0334MC | 01 | WA | REGENCE | OTHER | 1174830111 | 01 | WA | DSHS | OTHER | 0270986 | 01 | WA | DEPT OF L&I | OTHER | 0336MC | 01 | WA | REGENCE | OTHER | 0270990 | 01 | WA | DEPT OF L&I | OTHER | 0270993 | 01 | WA | DEPT OF L&I | OTHER | 0341MC | 01 | WA | REGENCE | OTHER | P00893794 | 01 | WA | RAILROAD MEDICARE | OTHER | 0332MC | 01 | WA | REGENCE | OTHER | 0335MC | 01 | WA | REGENCE | OTHER | 0271004 | 01 | WA | DEPT OF L&I | OTHER | 0338MC | 01 | WA | REGENCE | OTHER | 0340MC | 01 | WA | REGENCE | OTHER |