Provider Demographics
NPI:1023511409
Name:CLARK, SHELBY LEE (OTR/L)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:LEE
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 1:534 CAROLYN DR
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-1347
Mailing Address - Country:US
Mailing Address - Phone:419-204-0833
Mailing Address - Fax:
Practice Address - Street 1:205 NOLAN PKWY
Practice Address - Street 2:
Practice Address - City:ARCHBOLD
Practice Address - State:OH
Practice Address - Zip Code:43502-8404
Practice Address - Country:US
Practice Address - Phone:419-204-0833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT010084225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHOT010084OtherOTPTAT BOARD