Provider Demographics
NPI:1427485192
Name:CLARK, TANYA LEE (OTD, OTR/L)
Entity type:Individual
Prefix:DR
First Name:TANYA
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 LABBY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH GROSVENORDALE
Mailing Address - State:CT
Mailing Address - Zip Code:06255-1247
Mailing Address - Country:US
Mailing Address - Phone:607-643-2178
Mailing Address - Fax:
Practice Address - Street 1:113 LABBY RD
Practice Address - Street 2:
Practice Address - City:NORTH GROSVENORDALE
Practice Address - State:CT
Practice Address - Zip Code:06255-1247
Practice Address - Country:US
Practice Address - Phone:860-497-0239
Practice Address - Fax:860-497-0047
Is Sole Proprietor?:No
Enumeration Date:2013-09-26
Last Update Date:2024-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10108225X00000X
CT4145225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist