Provider Demographics
NPI:1346031564
Name:CLARK, KIMBERLY (BSC, COTA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:BSC, COTA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:BAHR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:34588 PEORIA RD
Mailing Address - Street 2:
Mailing Address - City:PEQUOT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56472-2879
Mailing Address - Country:US
Mailing Address - Phone:816-244-0933
Mailing Address - Fax:
Practice Address - Street 1:804 WRIGHT ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-4441
Practice Address - Country:US
Practice Address - Phone:218-522-8288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN202799224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant