Provider Demographics
NPI:1689810780
Name:CLARK, MAUREEN CHARBENEAU (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:CHARBENEAU
Last Name:CLARK
Suffix:
Gender:F
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 1:241 KIOWA DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8813
Mailing Address - Country:US
Mailing Address - Phone:601-291-5852
Mailing Address - Fax:
Practice Address - Street 1:241 KIOWA DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-8813
Practice Address - Country:US
Practice Address - Phone:601-291-5852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-20
Last Update Date:2008-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1722225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist