Provider Demographics
NPI:1164674321
Name:BURGESS, CLARISSA D (OTA)
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:D
Last Name:BURGESS
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 FRONTIER TRL
Mailing Address - Street 2:
Mailing Address - City:POCAHONTAS
Mailing Address - State:AR
Mailing Address - Zip Code:72455-1379
Mailing Address - Country:US
Mailing Address - Phone:870-926-9076
Mailing Address - Fax:870-892-9156
Practice Address - Street 1:199 FRONTIER TRL
Practice Address - Street 2:
Practice Address - City:POCAHONTAS
Practice Address - State:AR
Practice Address - Zip Code:72455-1379
Practice Address - Country:US
Practice Address - Phone:870-926-9076
Practice Address - Fax:870-892-9156
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT2015-026224Z00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist