Provider Demographics
NPI:1629798905
Name:CLARK, KHALEN DEWAR (OTD)
Entity Type:Individual
Prefix:DR
First Name:KHALEN
Middle Name:DEWAR
Last Name:CLARK
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3533 GREAT CYPRESS CIR APT 302
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33573-6863
Mailing Address - Country:US
Mailing Address - Phone:412-526-2921
Mailing Address - Fax:
Practice Address - Street 1:3533 GREAT CYPRESS CIR APT 302
Practice Address - Street 2:
Practice Address - City:RUSKIN
Practice Address - State:FL
Practice Address - Zip Code:33573-6863
Practice Address - Country:US
Practice Address - Phone:412-526-2921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology