Provider Demographics
NPI:1376546507
Name:CLARK, KIMBERLY L (OT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
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 1:28 CARSON DR
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-2189
Mailing Address - Country:US
Mailing Address - Phone:207-839-7117
Mailing Address - Fax:
Practice Address - Street 1:28 CARSON DR
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:ME
Practice Address - Zip Code:04038-2189
Practice Address - Country:US
Practice Address - Phone:207-839-7117
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT521174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MECLME 0599Medicare ID - Type UnspecifiedMEDICARE ID
ME040948Medicare UPIN