Basic Information
| Provider Information | |||||||||
| NPI: | 1538447560 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | RENAE | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 771 PILOT HOUSE DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236061990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578732302 | ||||||||
| FaxNumber: | 7578732306 | ||||||||
| Practice Location | |||||||||
| Address1: | 927 BATTLEFIELD BLVD N | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHESAPEAKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 233204853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574363350 | ||||||||
| FaxNumber: | 7575479367 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2011 | ||||||||
| LastUpdateDate: | 02/13/2015 | ||||||||
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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 | 2305207045 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 9400791 | 01 | VA | AETNA | OTHER | 1538447560 | 05 | VA | MEDICAID |