MEDICARE: BETHANY CLARK PT, DPT

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	PT28112	FL

General Provider Information

NPI Number	:	1417296260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETHANY CLARK PT, DPT

Provider Business Mailing Address
First Line	:	108 CAMDEN CAY DR
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32086-1814
Country	:	US
Telephone Number	:	440-864-5565
Fax Number	:

Provider Business Practice Location Address
First Line	:	9 PINE CONE DR STE 104B
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32137-8683
Country	:	US
Telephone Number	:	386-446-9716
Fax Number	:

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

Provider Enumeration Date	:	02/13/2013
Last Update Date	:	04/29/2019

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