Provider Demographics
NPI:1487611257
Name:CLARK, MARY ELIZABETH (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:FINK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1200 OAKLEAF WAY
Mailing Address - Street 2:STE B
Mailing Address - City:ALTOONA
Mailing Address - State:WI
Mailing Address - Zip Code:54720-2245
Mailing Address - Country:US
Mailing Address - Phone:715-839-9266
Mailing Address - Fax:715-839-8761
Practice Address - Street 1:1200 OAKLEAF WAY
Practice Address - Street 2:STE B
Practice Address - City:ALTOONA
Practice Address - State:WI
Practice Address - Zip Code:54720-2245
Practice Address - Country:US
Practice Address - Phone:715-839-9266
Practice Address - Fax:715-839-8761
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3727024225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40210700Medicaid
WI40210700Medicaid
WI000884587Medicare PIN