Provider Demographics
NPI:1750676425
Name:CLARK, ELEASHA (COTA)
Entity Type:Individual
Prefix:
First Name:ELEASHA
Middle Name:
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 1:673 BROOKHAVEN CT
Mailing Address - Street 2:APT 201
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-6170
Mailing Address - Country:US
Mailing Address - Phone:479-750-2020
Mailing Address - Fax:479-750-8967
Practice Address - Street 1:673 BROOKHAVEN CT
Practice Address - Street 2:APT 201
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-6170
Practice Address - Country:US
Practice Address - Phone:906-281-2271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT2016-002224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant