Provider Demographics
NPI:1518563469
Name:CLARK, CATHLEEN H
Entity Type:Individual
Prefix:
First Name:CATHLEEN
Middle Name:H
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 1:447 SILVER MINE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-4230
Mailing Address - Country:US
Mailing Address - Phone:719-322-8218
Mailing Address - Fax:
Practice Address - Street 1:447 SILVER MINE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-4230
Practice Address - Country:US
Practice Address - Phone:719-322-8218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000248224Z00000X
CO000248224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty