Provider Demographics
NPI:1447519590
Name:CLARK, ELIZABETH (PTA)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PARK STREET
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801
Mailing Address - Country:US
Mailing Address - Phone:518-926-2000
Mailing Address - Fax:518-926-2020
Practice Address - Street 1:100 PARK ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4413
Practice Address - Country:US
Practice Address - Phone:518-926-2000
Practice Address - Fax:518-926-2020
Is Sole Proprietor?:No
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003713-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant