Basic Information
| Provider Information | |||||||||
| NPI: | 1811904378 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 BLYTHE BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282035814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043554370 | ||||||||
| FaxNumber: | 7043554231 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 E WT HARRIS BLVD | ||||||||
| Address2: | CUITE 300 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282623485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045485780 | ||||||||
| FaxNumber: | 7045485876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| 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 | 9754 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7211891 | 05 | NY | MEDICAID |