Provider Demographics
NPI:1487070942
Name:CLARK, DEREK (ATC)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:LEETSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:15056-1200
Mailing Address - Country:US
Mailing Address - Phone:412-749-6001
Mailing Address - Fax:412-749-6017
Practice Address - Street 1:625 BEAVER ST
Practice Address - Street 2:
Practice Address - City:LEETSDALE
Practice Address - State:PA
Practice Address - Zip Code:15056-1200
Practice Address - Country:US
Practice Address - Phone:412-749-6001
Practice Address - Fax:412-749-6017
Is Sole Proprietor?:No
Enumeration Date:2014-03-07
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART001989A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer