Healthcare Provider Details

I. General information

NPI: 1619707551
Provider Name (Legal Business Name): CLYDE SUMMERS JR. PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 08/11/2024
Certification Date: 08/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

885 E WARNER RD
GILBERT AZ
85296-3075
US

IV. Provider business mailing address

515 W LEXINGTON ST
VAIL AZ
85641-0885
US

V. Phone/Fax

Practice location:
  • Phone: 480-681-6400
  • Fax:
Mailing address:
  • Phone: 321-439-9585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-033724
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: