MEDICARE: HEIDI CLARK P.T.

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	5501016656	MI

General Provider Information

NPI Number	:	1962821041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEIDI CLARK P.T.

Provider Business Mailing Address
First Line	:	29255 NORTHWESTERN HWY
Second Line	:	SUITE 300
City	:	SOUTHFIELD
State	:	MI
Zip	:	48034-1018
Country	:	US
Telephone Number	:	248-353-1234
Fax Number	:	248-353-1211

Provider Business Practice Location Address
First Line	:	2455 UNION LAKE RD
Second Line	:
City	:	COMMERCE TWP
State	:	MI
Zip	:	48382-3596
Country	:	US
Telephone Number	:	248-363-1234
Fax Number	:	248-353-1211

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

Provider Enumeration Date	:	04/15/2014
Last Update Date	:	04/15/2014

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Directions to “ HEIDI CLARK P.T.” Practice Location

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