Provider Demographics
NPI:1881150613
Name:CLARK, CHERYL (PTA A4176)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PTA A4176
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 LAUER TER # 5
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-4926
Mailing Address - Country:US
Mailing Address - Phone:301-587-0959
Mailing Address - Fax:
Practice Address - Street 1:5721 GROSVENOR LN
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-1833
Practice Address - Country:US
Practice Address - Phone:301-530-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA4176225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDA4176Medicaid