Provider Demographics
NPI:1346371564
Name:CLARK, CHRISTINA M (OT)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6815 NOBLE AVE
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3796
Mailing Address - Country:US
Mailing Address - Phone:818-901-6600
Mailing Address - Fax:818-997-7826
Practice Address - Street 1:6815 NOBLE AVE
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3796
Practice Address - Country:US
Practice Address - Phone:818-901-6600
Practice Address - Fax:818-997-7826
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT800174400000X, 225XH1200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered174400000XOther Service ProvidersSpecialist
Not Answered225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist