Provider Demographics
NPI:1689720088
Name:CLARK, SYLVIA E (COTA)
Entity Type:Individual
Prefix:
First Name:SYLVIA
Middle Name:E
Last Name:CLARK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 N UNION ST
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MS
Mailing Address - Zip Code:38967-1718
Mailing Address - Country:US
Mailing Address - Phone:662-428-9090
Mailing Address - Fax:
Practice Address - Street 1:605 N UNION ST
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MS
Practice Address - Zip Code:38967-1718
Practice Address - Country:US
Practice Address - Phone:662-428-9090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA1511224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant