Basic Information
| Provider Information | |||||||||
| NPI: | 1235786088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 47 WONSETTLER RD | ||||||||
| Address2: | |||||||||
| City: | SCENERY HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153601831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702345866 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1160 VAN VOORHIS RD | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265053437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045981100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2019 | ||||||||
| LastUpdateDate: | 08/26/2019 | ||||||||
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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 | 225100000X | 026115 | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 295590 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 003757 | WV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.