Provider Demographics
NPI:1760929962
Name:CLARK, DEONNA (OTR/L)
Entity Type:Individual
Prefix:
First Name:DEONNA
Middle Name:
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 1:406 RIVERCHASE BLVD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37115-2034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:406 RIVERCHASE BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-2034
Practice Address - Country:US
Practice Address - Phone:678-431-8776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5482225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist