Provider Demographics
NPI:1790579340
Name:CLARK, LAURA-LIN (OTD)
Entity type:Individual
Prefix:
First Name:LAURA-LIN
Middle Name:
Last Name:CLARK
Suffix:
Gender:
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 E DAMON AVE
Mailing Address - Street 2:
Mailing Address - City:TALLADEGA
Mailing Address - State:AL
Mailing Address - Zip Code:35160-3213
Mailing Address - Country:US
Mailing Address - Phone:256-698-0013
Mailing Address - Fax:
Practice Address - Street 1:205 SOUTH ST E
Practice Address - Street 2:
Practice Address - City:TALLADEGA
Practice Address - State:AL
Practice Address - Zip Code:35160-2411
Practice Address - Country:US
Practice Address - Phone:256-761-3366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6594225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist