Provider Demographics
NPI:1942523634
Name:CLARK, SHEREE ANN (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:SHEREE
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 DIAMOND GREEN GROVE ROAD
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:KY
Mailing Address - Zip Code:42404
Mailing Address - Country:US
Mailing Address - Phone:270-635-0789
Mailing Address - Fax:
Practice Address - Street 1:323 DIAMOND GREEN GROVE ROAD
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:KY
Practice Address - Zip Code:42404
Practice Address - Country:US
Practice Address - Phone:270-635-0789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA1846224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant