Healthcare Provider Details

I. General information

NPI: 1043198344
Provider Name (Legal Business Name): BRIANNA CLARK PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2025
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2548 CUMBERLAND AVE STE 100
WEST LAFAYETTE IN
47906-4083
US

IV. Provider business mailing address

12788 TOUCHDOWN DR
FISHERS IN
46037-9532
US

V. Phone/Fax

Practice location:
  • Phone: 317-802-2000
  • Fax: 317-802-2050
Mailing address:
  • Phone: 317-544-8926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP048794T
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05016133A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP053478T
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number16812
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: