Provider Demographics
NPI:1023500907
Name:CLARK, CONNIE (DPT, PT)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2501 RANCH ROAD 620 S STE 140
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-6416
Practice Address - Country:US
Practice Address - Phone:512-527-6944
Practice Address - Fax:512-572-7805
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHCP001210T225100000X
COPTL.0015088225100000X
TX225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist