Healthcare Provider Details

I. General information

NPI: 1326567116
Provider Name (Legal Business Name): MARY DENISE CLANTON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 09/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9700 W 62ND ST
SHAWNEE KS
66203-3220
US

IV. Provider business mailing address

14875 S SUMMIT ST
OLATHE KS
66062-3328
US

V. Phone/Fax

Practice location:
  • Phone: 913-384-0800
  • Fax:
Mailing address:
  • Phone: 913-244-5020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number14-01813
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: