Provider Demographics
NPI:1508226531
Name:CLARK, MICHAEL (OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
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 1:503 N 43RD ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-7203
Mailing Address - Country:US
Mailing Address - Phone:206-290-5619
Mailing Address - Fax:
Practice Address - Street 1:13010 NE 20TH ST
Practice Address - Street 2:STE 300
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-2034
Practice Address - Country:US
Practice Address - Phone:425-644-6328
Practice Address - Fax:425-644-6295
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60622837225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist