MEDICARE: DR. SUSANNA CLARK PT, DPT, OCS

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	PTL0013866	CO
2	225100000X	Physical Therapist	PT010027	GA

General Provider Information

NPI Number	:	1366713521
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSANNA CLARK PT, DPT, OCS

Provider Business Mailing Address
First Line	:	10450 PARK MEADOWS DR STE 103
Second Line	:
City	:	LONE TREE
State	:	CO
Zip	:	80124-5528
Country	:	US
Telephone Number	:	303-790-7877
Fax Number	:

Provider Business Practice Location Address
First Line	:	10450 PARK MEADOWS DR STE 103
Second Line	:
City	:	LONE TREE
State	:	CO
Zip	:	80124-5528
Country	:	US
Telephone Number	:	303-790-7877
Fax Number	:

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

Provider Enumeration Date	:	01/19/2012
Last Update Date	:	06/25/2019

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