Basic Information
| Provider Information | |||||||||
| NPI: | 1619162542 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1406-77 CARLTON ST | ||||||||
| Address2: | |||||||||
| City: | TORONTO | ||||||||
| State: | ON | ||||||||
| PostalCode: | M5B 2J7 | ||||||||
| CountryCode: | CA | ||||||||
| TelephoneNumber: | 6473427123 | ||||||||
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| Practice Location | |||||||||
| Address1: | 64 DANBURY RD | ||||||||
| Address2: | |||||||||
| City: | WILTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068974429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002780332 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2007 | ||||||||
| LastUpdateDate: | 01/16/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 717 | AR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 1174211 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 028934-1 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.