MEDICARE: CAITLIN MORIAH 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	2251X0800X	Orthopedic Physical Therapist	PT012941	GA

General Provider Information

NPI Number	:	1649791005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAITLIN MORIAH CLARK PT, DPT

Provider Business Mailing Address
First Line	:	1995 N PARK PL SE STE 410
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30339-2072
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1995 N PARK PL SE STE 410
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30339-2072
Country	:	US
Telephone Number	:	770-850-0390
Fax Number	:

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

Provider Enumeration Date	:	07/06/2017
Last Update Date	:	07/06/2017

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