Provider Demographics
NPI:1184285454
Name:CLARK, DENISE (OTR/L)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:3085 N KREPPS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-9048
Mailing Address - Country:US
Mailing Address - Phone:989-292-2691
Mailing Address - Fax:
Practice Address - Street 1:1101 S SCOTT RD
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-8044
Practice Address - Country:US
Practice Address - Phone:989-224-8936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007046225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist