Provider Demographics
NPI:1770210478
Name:CLARK, BRENNA ALYSE (OTR/L)
Entity type:Individual
Prefix:
First Name:BRENNA
Middle Name:ALYSE
Last Name: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 1:7110 N 153RD CIR
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:NE
Mailing Address - Zip Code:68007-1409
Mailing Address - Country:US
Mailing Address - Phone:402-960-0932
Mailing Address - Fax:
Practice Address - Street 1:20650 GLENN ST
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-2324
Practice Address - Country:US
Practice Address - Phone:402-960-0932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2632225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist