Provider Demographics
NPI:1164512406
Name:CLARK-MILLER, ANGELIQUE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:ANGELIQUE
Middle Name:
Last Name:CLARK-MILLER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 GOSS AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1239
Mailing Address - Country:US
Mailing Address - Phone:502-636-1200
Mailing Address - Fax:502-636-0351
Practice Address - Street 1:1227 GOSS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1239
Practice Address - Country:US
Practice Address - Phone:502-636-1200
Practice Address - Fax:502-636-0351
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR2290225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist