Provider Demographics
NPI:1487209722
Name:CLARK, DEMETRIA
Entity Type:Individual
Prefix:
First Name:DEMETRIA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 LODGE AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43609-1173
Mailing Address - Country:US
Mailing Address - Phone:567-702-1078
Mailing Address - Fax:
Practice Address - Street 1:709 LODGE AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43609-2915
Practice Address - Country:US
Practice Address - Phone:567-702-1078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-05
Last Update Date:2022-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)Group - Single Specialty
No343800000XTransportation ServicesSecured Medical Transport (VAN)
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children