Healthcare Provider Details

I. General information

NPI: 1861316010
Provider Name (Legal Business Name): KIRSTEN ELIZABETH CLARK PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2026
Last Update Date: 08/08/2026
Certification Date: 08/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1185 W CARMEL DR BLDG C-1
CARMEL IN
46032-8706
US

IV. Provider business mailing address

17929 GALVIN WAY UNIT 106
NOBLESVILLE IN
46062-0222
US

V. Phone/Fax

Practice location:
  • Phone: 317-415-6980
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: