Provider Demographics
NPI:1255086054
Name:CLARK, ALLYSSA-ASHLEY MARIE (LMT)
Entity type:Individual
Prefix:
First Name:ALLYSSA-ASHLEY
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 SE 13TH CT APT 1
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-2616
Mailing Address - Country:US
Mailing Address - Phone:239-220-2128
Mailing Address - Fax:
Practice Address - Street 1:13620 METROPOLIS AVE STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-3406
Practice Address - Country:US
Practice Address - Phone:239-220-2128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA80966225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist