Provider Demographics
NPI:1932774965
Name:CLARKE, CEZANNE OSANA (OTR/L)
Entity Type:Individual
Prefix:
First Name:CEZANNE
Middle Name:OSANA
Last Name:CLARKE
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 1:524 HILLANDALE PARK DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-8833
Mailing Address - Country:US
Mailing Address - Phone:860-532-8947
Mailing Address - Fax:
Practice Address - Street 1:2540 WIGGINS ST STE E
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4312
Practice Address - Country:US
Practice Address - Phone:404-606-3755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121601225X00000X, 2279H0200X
OT008489225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No2279H0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredHome Health