Provider Demographics
NPI:1932598992
Name:CLARK, CARA LEANNE (MOTR/L)
Entity Type:Individual
Prefix:
First Name:CARA
Middle Name:LEANNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:CARA
Other - Middle Name:LEANNE
Other - Last Name:RUGGERI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOTR/L
Mailing Address - Street 1:15708 HUNTCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-3854
Mailing Address - Country:US
Mailing Address - Phone:586-293-1234
Mailing Address - Fax:
Practice Address - Street 1:30801 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48082-1732
Practice Address - Country:US
Practice Address - Phone:586-293-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-14
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008898225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist