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General NPI Number Information
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NPI Number | 1992315287
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Entity Type | Individual
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Provider Name | CRYSTA CLARK DPT
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Gender | Female
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Dates
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Enumeration Date | 08/03/2020
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Last Update Date | 08/03/2020
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Provider Practice Location Address
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Address Line | 10222 74TH ST STE 211
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City | KENOSHA
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State | WI
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Zip | 53142-6810
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Country | US
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Telephone | 262-925-5020
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Fax | 262-925-5021
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Provider Business Mailing Address
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Address Line | 3921 30TH AVE STE C
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City | KENOSHA
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State | WI
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Zip | 53144-1939
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Country | US
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Telephone | 262-925-5000
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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 | 15117
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License Number State | WI
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