MEDICARE: MRS. MELISSA GRAY CLARK R. P. T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT0751	MS

General Provider Information

NPI Number	:	1023103207
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MELISSA GRAY CLARK R. P. T.

Provider Business Mailing Address
First Line	:	10851 ROAD 327
Second Line	:
City	:	UNION
State	:	MS
Zip	:	39365-7215
Country	:	US
Telephone Number	:	601-656-0075
Fax Number	:	601-650-1972

Provider Business Practice Location Address
First Line	:	1058 HOLLAND AVE
Second Line	:
City	:	PHILADELPHIA
State	:	MS
Zip	:	39350-9121
Country	:	US
Telephone Number	:	601-650-9111
Fax Number	:	601-650-1972

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	07/08/2007

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