MEDICARE: MS. ELSA MARIE CLARK MPT

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	PT7723	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	UJ966	OTHER	FL	MEDICARE HF

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124208319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELSA MARIE CLARK MPT

Provider Business Mailing Address
First Line	:	3300 S FISKE BLVD
Second Line	:
City	:	ROCKLEDGE
State	:	FL
Zip	:	32955-4306
Country	:	US
Telephone Number	:	321-434-5820
Fax Number	:

Provider Business Practice Location Address
First Line	:	220 S COURTENAY PKWY STE B
Second Line	:
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32952-4893
Country	:	US
Telephone Number	:	321-434-5820
Fax Number	:

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

Provider Enumeration Date	:	11/06/2007
Last Update Date	:	01/16/2026

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