Active NPI
Susan Clark
- Physical Therapy Assistant
- Round Rock, TX
National Provider Identifier
1144593336
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapy Assistant
- License
- 2068753
- Practice address
- 1250 S a W Grimes Blvd
Round Rock, TX 78664-7429 - Phone
- (512) 310-7665
- NPI assigned
- Feb 17, 2012
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapy Assistant | 225200000X | 2068753 | TX | Primary |
Addresses
Primary practice location
1250 S a W Grimes Blvd
Round Rock, TX 78664-7429
Mailing address
1250 S a W Grimes Blvd
Round Rock, TX 78664-7429
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0031DG | Other | TX | BLUE CROSS BLUE SHIELD |
| 0944746-02 | Medicaid | TX |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2068753 | TX | MD | Physical Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1329436800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1329436800000",
"number": "1144593336",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1250 S A W GRIMES BLVD",
"city": "ROUND ROCK",
"state": "TX",
"postal_code": "786647429"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1250 S A W GRIMES BLVD",
"city": "ROUND ROCK",
"state": "TX",
"postal_code": "786647429",
"telephone_number": "512-310-7665"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "SUSAN",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2012-02-17",
"last_updated": "2012-02-17",
"status": "A"
},
"taxonomies": [
{
"code": "225200000X",
"taxonomy_group": "",
"desc": "Physical Therapy Assistant",
"state": "TX",
"license": "2068753",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD",
"identifier": "0031DG",
"state": "TX"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "0944746-02",
"state": "TX"
}
],
"endpoints": [],
"other_names": []
}Other providers in Round Rock, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 17, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.