Individual
HEATHER CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PT, DPT
Contact information
Practice address
10790 W OVERLAND RD, BOISE, ID 83709-1329
(208) 322-8709
(208) 322-8710
Mailing address
1560 S CAROL ST, MERIDIAN, ID 83646-1839
(208) 288-1155
(208) 288-0424
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT-4128
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PT-4128
IDAHO STATE LICENSE
ID
Enumeration date
08/20/2015
Last updated
08/28/2015
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