Provider Demographics
NPI:1649433301
Name:HENDRICKS-CLARK, VIVIENNE MINESA (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:VIVIENNE
Middle Name:MINESA
Last Name:HENDRICKS-CLARK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 LARSSON ST
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5943
Mailing Address - Country:US
Mailing Address - Phone:310-318-2961
Mailing Address - Fax:
Practice Address - Street 1:701 LARSSON ST
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-5943
Practice Address - Country:US
Practice Address - Phone:310-318-2961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4654225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation