Provider Demographics
NPI:1235907999
Name:CLARK, HAILEY SANDA (OTR/L)
Entity Type:Individual
Prefix:
First Name:HAILEY
Middle Name:SANDA
Last Name:CLARK
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 1:95 WEST ST UNIT 1215
Mailing Address - Street 2:
Mailing Address - City:WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02081-1857
Mailing Address - Country:US
Mailing Address - Phone:508-507-1547
Mailing Address - Fax:
Practice Address - Street 1:160 MAIN ST # 4037
Practice Address - Street 2:
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081-4037
Practice Address - Country:US
Practice Address - Phone:508-660-3080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA41678225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist