Healthcare Provider Details

I. General information

NPI: 1013451095
Provider Name (Legal Business Name): JOSHUA CLARK NSCA-CPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2016
Last Update Date: 12/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 SCHOOL ST
WATERTOWN MA
02472-4149
US

IV. Provider business mailing address

170 SCHOOL ST
WATERTOWN MA
02472-4149
US

V. Phone/Fax

Practice location:
  • Phone: 774-279-1044
  • Fax:
Mailing address:
  • Phone: 774-279-1044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberS62236208
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberS62236208
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: