Provider Demographics
NPI:1740586932
Name:CLARK, JOHN CASEY
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CASEY
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2294 LYONS STATION RD
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:KY
Mailing Address - Zip Code:40051-8723
Mailing Address - Country:US
Mailing Address - Phone:859-576-9382
Mailing Address - Fax:
Practice Address - Street 1:448 LEWIS HARGETT CIR
Practice Address - Street 2:SUITE 100
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3594
Practice Address - Country:US
Practice Address - Phone:859-313-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-04
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR4232225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist