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General NPI Number Information
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NPI Number | 1164021093
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Entity Type | Individual
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Provider Name | JOSEPH BRADY CLARK PTA
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Gender | Male
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Dates
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Enumeration Date | 10/21/2020
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Last Update Date | 10/21/2020
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Provider Practice Location Address
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Address Line | 1030 SCOTT DR
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City | PRESCOTT
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State | AZ
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Zip | 86301-4737
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Country | US
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Telephone | 928-778-2450
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Fax |
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Provider Business Mailing Address
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Address Line | 554 CAMPBELL ST
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City | PRESCOTT
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State | AZ
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Zip | 86301-2521
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Country | US
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Telephone | 928-830-8572
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA-012200
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License Number State | AZ
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