Provider Demographics
NPI:1518386382
Name:CLARK, THREESE
Entity type:Individual
Prefix:
First Name:THREESE
Middle Name:
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 1:36 OLD OAK RD
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:VA
Mailing Address - Zip Code:23960-7925
Mailing Address - Country:US
Mailing Address - Phone:434-391-9950
Mailing Address - Fax:
Practice Address - Street 1:36 OLD OAK RD
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:VA
Practice Address - Zip Code:23960-7925
Practice Address - Country:US
Practice Address - Phone:434-391-9950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119003695225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist