Provider Demographics
NPI:1154678969
Name:LOVELY CLARK, KASSIE JO (MS,OT/L)
Entity type:Individual
Prefix:
First Name:KASSIE
Middle Name:JO
Last Name:LOVELY CLARK
Suffix:
Gender:F
Credentials:MS,OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 GRIFFIN RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MAPLETON
Mailing Address - State:ME
Mailing Address - Zip Code:04757-4415
Mailing Address - Country:US
Mailing Address - Phone:207-227-6538
Mailing Address - Fax:
Practice Address - Street 1:79 BLAKE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-2474
Practice Address - Country:US
Practice Address - Phone:207-764-3036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
METO2657225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist