Provider Demographics
NPI:1265456735
Name:SIMS, CLARENCE ANDREW (OT)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:ANDREW
Last Name:SIMS
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1917 N LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2634
Mailing Address - Country:US
Mailing Address - Phone:208-664-8194
Mailing Address - Fax:208-667-1847
Practice Address - Street 1:1917 N LAKEWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2634
Practice Address - Country:US
Practice Address - Phone:208-664-8194
Practice Address - Fax:208-667-1847
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-782225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDW1219OtherBLUE CROSS PIN
WA211798OtherWA LABOR & INDUSTRY PIN
ID000010157662OtherBLUE SHIELD PIN
ID1654189Medicare PIN