Provider Demographics
NPI:1558637181
Name:CLARKE, DAVID CHARLES (OTR/L)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:CHARLES
Last Name:CLARKE
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 1:15 FAIRFIELD ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-1823
Mailing Address - Country:US
Mailing Address - Phone:718-356-8575
Mailing Address - Fax:
Practice Address - Street 1:15 FAIRFIELD ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-1823
Practice Address - Country:US
Practice Address - Phone:718-356-8575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY63-004221225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist