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NPI Code Detail

MEDICARE: LOUISE CLARK PT, DPT

MEDICARE: LOUISE 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
1225100000XPhysical Therapist61553616WA

General Provider Information

NPI Number : 1659113876
Entity Type Code : Individual
Provider Name (Legal Business Name) : LOUISE CLARK PT, DPT
Provider Business Mailing Address
First Line : 4560 SE INTERNATIONAL WAY STE 100
Second Line :
City : MILWAUKIE
State : OR
Zip : 97222-4628
Country : US
Telephone Number : 503-853-3173
Fax Number :
Provider Business Practice Location Address
First Line : 6720 E GREEN LAKE WAY N
Second Line :
City : SEATTLE
State : WA
Zip : 98103-5439
Country : US
Telephone Number : 503-853-3173
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/10/2024
Last Update Date : 06/10/2024

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