Basic Information
| Provider Information | |||||||||
| NPI: | 1083251276 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 576 BROADHOLLOW RD STE PROEX | ||||||||
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| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117475002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313595859 | ||||||||
| FaxNumber: | 6313960864 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 SOLDIERS FIELD RD | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021351032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8575405252 | ||||||||
| FaxNumber: | 8575405269 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2019 | ||||||||
| LastUpdateDate: | 12/06/2019 | ||||||||
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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 | 225100000X | 9421 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.