Provider Demographics
NPI:1710347612
Name:CLARK, LORI (COTA/L)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
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 1:4487 TRAIL ST
Mailing Address - Street 2:
Mailing Address - City:NORCO
Mailing Address - State:CA
Mailing Address - Zip Code:92860-2487
Mailing Address - Country:US
Mailing Address - Phone:951-415-3440
Mailing Address - Fax:
Practice Address - Street 1:4487 TRAIL ST
Practice Address - Street 2:
Practice Address - City:NORCO
Practice Address - State:CA
Practice Address - Zip Code:92860-2487
Practice Address - Country:US
Practice Address - Phone:951-415-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA 408171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor