Basic Information
| Provider Information | |||||||||
| NPI: | 1205028172 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PIPER | ||||||||
| FirstName: | CLARISSAL | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 YOUNG STREET | ||||||||
| Address2: | |||||||||
| City: | UNIONTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703893513 | ||||||||
| FaxNumber: | 2703894702 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 YOUNG STREET | ||||||||
| Address2: | |||||||||
| City: | UNIONTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703893513 | ||||||||
| FaxNumber: | 2703894702 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2007 | ||||||||
| LastUpdateDate: | 08/15/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | A01193 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 12500765 | 05 | KY | MEDICAID |