Basic Information
| Provider Information | |||||||||
| NPI: | 1326063603 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 CENTRAL ST | ||||||||
| Address2: | SUITE H | ||||||||
| City: | BYFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019221233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9784624500 | ||||||||
| FaxNumber: | 9784621275 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 N MOUNTAIN RD | ||||||||
| Address2: | SUITE A-212 | ||||||||
| City: | NEWINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061111412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609530676 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 225100000X | 3141 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.