=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336113497
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GABRIEL M CLARK MPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2006
-----------------------------------------------------
Last Update Date | 09/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 909 N DALE MABRY HWY SUITE 300
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33609-1251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-978-9700
-----------------------------------------------------
Fax | 813-558-6187
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13020 N TELECOM PKWY
-----------------------------------------------------
City | TEMPLE TERRACE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33637-0925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-978-9700
-----------------------------------------------------
Fax | 813-558-6187
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT011347
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT 5940
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------