Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 1544 | SD |
Y | 225100000X | Physical Therapist | 2157 | MT |
N | 225100000X | Physical Therapist | 2759 | ID |
NPI | 1003196718 |
---|---|
Provider Name | Shelley Clark |
First Address | Missoula, MT 59808-9048 |
Second Address | Missoula, MT 59808-9048 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/08/2011 |
Last Update Date | 25/08/2011 |