Provider Demographics
NPI:1134288400
Name:CLARK, JULIA MARIE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:JULIA
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 HIGH RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-1407
Mailing Address - Country:US
Mailing Address - Phone:708-334-1095
Mailing Address - Fax:855-834-3810
Practice Address - Street 1:621 HIGH RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:IL
Practice Address - Zip Code:60172-1407
Practice Address - Country:US
Practice Address - Phone:708-334-1095
Practice Address - Fax:855-834-3810
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.007110225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist