Provider Demographics
NPI:1710573969
Name:CLARK, EMMALEE (OTR)
Entity Type:Individual
Prefix:
First Name:EMMALEE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 S FORGOTTEN LN
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9319
Mailing Address - Country:US
Mailing Address - Phone:435-770-5917
Mailing Address - Fax:
Practice Address - Street 1:209 W 300 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-3809
Practice Address - Country:US
Practice Address - Phone:435-716-8535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13444587-4201225X00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty