Provider Demographics
NPI:1023103207
Name:CLARK, MELISSA GRAY (R P T)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:GRAY
Last Name:CLARK
Suffix:
Gender:F
Credentials:R P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10851 ROAD 327
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:MS
Mailing Address - Zip Code:39365-7215
Mailing Address - Country:US
Mailing Address - Phone:601-656-0075
Mailing Address - Fax:601-650-1972
Practice Address - Street 1:1058 HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-9121
Practice Address - Country:US
Practice Address - Phone:601-650-9111
Practice Address - Fax:601-650-1972
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0751225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist