Provider Demographics
NPI:1912307109
Name:CLARK, TERESA M (OTR)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:M
Last Name:CLARK
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 1:19302 FRIESLAND RD
Mailing Address - Street 2:
Mailing Address - City:HINCKLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55037-4768
Mailing Address - Country:US
Mailing Address - Phone:320-225-3356
Mailing Address - Fax:320-225-3370
Practice Address - Street 1:301 HIGHWAY 65 S
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1899
Practice Address - Country:US
Practice Address - Phone:320-225-3356
Practice Address - Fax:320-225-3370
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103264225X00000X
WI3919-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist