Basic Information
| Provider Information | |||||||||
| NPI: | 1437762051 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | ALLIE | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2491 SAWMILL RD APT 1105 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875055677 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 404 HUNTER ST | ||||||||
| Address2: | |||||||||
| City: | ESPANOLA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875322655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057534123 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2020 | ||||||||
| LastUpdateDate: | 08/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT5724 | NM | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.