Provider Demographics
NPI:1881015907
Name:CLARK, PAULA JEAN (OTA)
Entity Type:Individual
Prefix:MRS
First Name:PAULA
Middle Name:JEAN
Last Name:CLARK
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 608
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-0608
Mailing Address - Country:US
Mailing Address - Phone:209-479-2754
Mailing Address - Fax:
Practice Address - Street 1:308 E 3RD ST
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-2140
Practice Address - Country:US
Practice Address - Phone:406-293-3032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2700224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant