Provider Demographics
NPI:1124285069
Name:CLARK, MARY SUSAN (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SUSAN
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 1:46 MILLBROOK RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-5657
Mailing Address - Country:US
Mailing Address - Phone:540-226-7996
Mailing Address - Fax:540-657-1095
Practice Address - Street 1:46 MILLBROOK RD
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-5657
Practice Address - Country:US
Practice Address - Phone:540-226-7996
Practice Address - Fax:540-657-1095
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119003184225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist