Provider Demographics
NPI:1841374329
Name:CLARKE, TAMMY JANE (OTA)
Entity type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:JANE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:MRS
Other - First Name:TAMMY
Other - Middle Name:JANE
Other - Last Name:POMERVILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTA
Mailing Address - Street 1:4016 COUNTY ROUTE #24
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:NY
Mailing Address - Zip Code:13684
Mailing Address - Country:US
Mailing Address - Phone:315-347-3093
Mailing Address - Fax:
Practice Address - Street 1:420 GAFFNEY DRIVE
Practice Address - Street 2:JEFFERSON REHABILITATION CENTER
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:315-788-2730
Practice Address - Fax:315-782-6612
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005576-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant