Provider Demographics
NPI:1629771316
Name:CLARK, KARNA LEIAN (COTA/L)
Entity Type:Individual
Prefix:
First Name:KARNA
Middle Name:LEIAN
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 1:14756 MCMILLIN LN
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-7393
Mailing Address - Country:US
Mailing Address - Phone:918-635-5833
Mailing Address - Fax:
Practice Address - Street 1:213 E REDWOOD AVE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-2811
Practice Address - Country:US
Practice Address - Phone:918-774-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOT-A1770224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty