MEDICARE: STACIE 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	PT06825	PA

General Provider Information

NPI Number	:	1770599292
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACIE CLARK MPT

Provider Business Mailing Address
First Line	:	3449 HADLEY RD
Second Line	:
City	:	HADLEY
State	:	PA
Zip	:	16130-2821
Country	:	US
Telephone Number	:	724-253-1044
Fax Number	:

Provider Business Practice Location Address
First Line	:	2447 MERCER ST
Second Line	:
City	:	STONEBORO
State	:	PA
Zip	:	16153-2711
Country	:	US
Telephone Number	:	724-376-3666
Fax Number	:	724-376-2460

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

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	02/18/2011

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