Provider Demographics
NPI:1700377462
Name:CLARKE, LESHA DANIELLE (OTR)
Entity Type:Individual
Prefix:
First Name:LESHA
Middle Name:DANIELLE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52527 TRAILWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-8303
Mailing Address - Country:US
Mailing Address - Phone:734-645-8579
Mailing Address - Fax:
Practice Address - Street 1:33010 NORTHWESTERN HWY
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3690
Practice Address - Country:US
Practice Address - Phone:248-538-5165
Practice Address - Fax:248-538-5164
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006899225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist