Provider Demographics
NPI:1982182309
Name:CLARK, ANDREA K
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:K
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20318 180TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKWELL
Mailing Address - State:IA
Mailing Address - Zip Code:50469-8680
Mailing Address - Country:US
Mailing Address - Phone:402-560-3651
Mailing Address - Fax:
Practice Address - Street 1:920 GOLDENROD LN
Practice Address - Street 2:
Practice Address - City:HICKMAN
Practice Address - State:NE
Practice Address - Zip Code:68372-9509
Practice Address - Country:US
Practice Address - Phone:402-560-3651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2227225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist