Provider Demographics
NPI:1245372929
Name:CLARK, JULIE LYNN
Entity type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:LYNN
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 1:2446 FOREST LEAF PKWY
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63011-1847
Mailing Address - Country:US
Mailing Address - Phone:636-458-2584
Mailing Address - Fax:636-458-2584
Practice Address - Street 1:2446 FOREST LEAF PKWY
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63011-1847
Practice Address - Country:US
Practice Address - Phone:636-458-2584
Practice Address - Fax:636-458-2584
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000157767225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics