MEDICARE: MRS. ELIZABETH W CLARK PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT2596	ME

General Provider Information

NPI Number	:	1548461775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELIZABETH W CLARK PT

Provider Business Mailing Address
First Line	:	230 LAKE ST
Second Line	:
City	:	AUBURN
State	:	ME
Zip	:	04210-4111
Country	:	US
Telephone Number	:	207-784-0240
Fax Number	:

Provider Business Practice Location Address
First Line	:	230 LAKE ST
Second Line	:
City	:	AUBURN
State	:	ME
Zip	:	04210-4111
Country	:	US
Telephone Number	:	207-784-0240
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2007
Last Update Date	:	07/08/2007

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