Provider Demographics
NPI:1518372176
Name:CLARK, DANIELLE (COTA/L)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 E LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:OH
Mailing Address - Zip Code:44420-2720
Mailing Address - Country:US
Mailing Address - Phone:330-978-8926
Mailing Address - Fax:
Practice Address - Street 1:457 E LIBERTY ST
Practice Address - Street 2:
Practice Address - City:GIRARD
Practice Address - State:OH
Practice Address - Zip Code:44420-2720
Practice Address - Country:US
Practice Address - Phone:330-978-8926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2014-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA. 05092224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant