Provider Demographics
NPI:1851732721
Name:CLARKE, JUDITH RENEE (COTA)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:RENEE
Last Name:CLARKE
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 1:6001 WILORA LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-2833
Mailing Address - Country:US
Mailing Address - Phone:704-900-6072
Mailing Address - Fax:
Practice Address - Street 1:6001 WILORA LAKE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-2833
Practice Address - Country:US
Practice Address - Phone:704-900-6072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA13081224Z00000X
NC9278224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant