Provider Demographics
NPI:1952868879
Name:CLARK, CLIFFORD LLOYD JR (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:CLIFFORD
Middle Name:LLOYD
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1035
Mailing Address - Street 2:
Mailing Address - City:DANA
Mailing Address - State:NC
Mailing Address - Zip Code:28724
Mailing Address - Country:US
Mailing Address - Phone:828-272-5202
Mailing Address - Fax:
Practice Address - Street 1:501 ESSEOLA DRIVE
Practice Address - Street 2:
Practice Address - City:SALUDA
Practice Address - State:NC
Practice Address - Zip Code:28773
Practice Address - Country:US
Practice Address - Phone:828-749-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4167224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant