Provider Demographics
NPI:1225334964
Name:CLARK, NANCY ELLEN (MBA, OT/L)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:ELLEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MBA, OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3080 HECLA ST
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-6320
Mailing Address - Country:US
Mailing Address - Phone:406-491-4157
Mailing Address - Fax:
Practice Address - Street 1:3080 HECLA ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-6320
Practice Address - Country:US
Practice Address - Phone:406-491-4157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-27
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT297225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist