Provider Demographics
NPI:1447907274
Name:CLARK, LANE (PT, DPT)
Entity type:Individual
Prefix:
First Name:LANE
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 S ALMA DR STE 110
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-3810
Mailing Address - Country:US
Mailing Address - Phone:214-383-0623
Mailing Address - Fax:
Practice Address - Street 1:820 S ALMA DR STE 110
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-3810
Practice Address - Country:US
Practice Address - Phone:214-383-0623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1357609208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation