Provider Demographics
NPI:1104247212
Name:CLARK, JOEL I (COTA)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:CLARK
Suffix:I
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 COBB ST
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-2603
Mailing Address - Country:US
Mailing Address - Phone:434-391-6061
Mailing Address - Fax:
Practice Address - Street 1:2003 COBB ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-2603
Practice Address - Country:US
Practice Address - Phone:434-391-6061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-17
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000186224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant