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General NPI Number Information
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NPI Number | 1003196718
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Entity Type | Individual
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Provider Name | SHELLEY CLARK DPT
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Gender | Female
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Dates
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Enumeration Date | 08/25/2011
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Last Update Date | 08/25/2011
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Provider Practice Location Address
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Address Line | 2803 ROCKRIDGE CT APT 5
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City | MISSOULA
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State | MT
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Zip | 59808-9048
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Country | US
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Telephone | 605-661-0879
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Fax |
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Provider Business Mailing Address
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Address Line | 2803 ROCKRIDGE CT APT 5
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City | MISSOULA
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State | MT
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Zip | 59808-9048
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Country | US
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Telephone | 605-661-0879
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 2759
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 1544
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License Number State | SD
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Taxonomy #3
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 2157
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License Number State | MT
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