Provider Demographics
NPI:1356858633
Name:CLARK, KELLY SUE (OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SUE
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 1:6076 BRISTOL PKWY STE 105
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90230-6600
Mailing Address - Country:US
Mailing Address - Phone:310-642-7700
Mailing Address - Fax:
Practice Address - Street 1:6076 BRISTOL PKWY STE 105
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90230-6600
Practice Address - Country:US
Practice Address - Phone:310-642-7700
Practice Address - Fax:310-642-7700
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12874225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist