Active NPI
Kaitlin Effie Clark
- Physical Therapist
- Watertown, NY
National Provider Identifier
1396383170
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- 43108
- Practice address
- 830 Washington St
Watertown, NY 13601-4034 - Phone
- (315) 785-4088
- NPI assigned
- Dec 12, 2019
- 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 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | 11313 | GA | |
| Physical Therapist | 225100000X | 43108 | NY | Primary |
Addresses
Primary practice location
830 Washington St
Watertown, NY 13601-4034
Mailing address
1336 Marra Dr
Watertown, NY 13601-4434
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 |
|---|---|---|---|
| 43108 | NY | MD | Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1576108800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1576108800000",
"number": "1396383170",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1336 MARRA DR",
"city": "WATERTOWN",
"state": "NY",
"postal_code": "136014434"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "830 WASHINGTON ST",
"city": "WATERTOWN",
"state": "NY",
"postal_code": "136014034",
"telephone_number": "315-785-4088"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "KAITLIN",
"middle_name": "EFFIE",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2019-12-12",
"last_updated": "2019-12-12",
"certification_date": "2019-12-12",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "GA",
"license": "11313",
"primary": false
},
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "NY",
"license": "43108",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Watertown, NY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 12, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.