=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851644165
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE J CLARK DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2012
-----------------------------------------------------
Last Update Date | 07/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5424 DISCOVERY PARK BLVD SUITE 101
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23188-2904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-345-2512
-----------------------------------------------------
Fax | 757-345-0859
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 298 NAT TURNER BLVD S
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23606-3074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-596-1900
-----------------------------------------------------
Fax | 866-420-0168
-----------------------------------------------------
=====================================================
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 | 2305204753
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------