Provider Demographics
NPI:1689105157
Name:CLARK, CASSANDRA (OT)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:CASSANDRA
Other - Middle Name:
Other - Last Name:LYONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12 BLUEBERRY DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6891
Mailing Address - Country:US
Mailing Address - Phone:207-671-4416
Mailing Address - Fax:
Practice Address - Street 1:12 WESTBROOK CMN
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-2819
Practice Address - Country:US
Practice Address - Phone:207-791-7210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-25
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT3297225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist