Provider Demographics
NPI:1104585397
Name:CLARK, CAPRI N
Entity type:Individual
Prefix:
First Name:CAPRI
Middle Name:N
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:EMPORIUM
Mailing Address - State:PA
Mailing Address - Zip Code:15834-1202
Mailing Address - Country:US
Mailing Address - Phone:814-594-1030
Mailing Address - Fax:
Practice Address - Street 1:17083 US-6
Practice Address - Street 2:
Practice Address - City:SMETHPORT
Practice Address - State:PA
Practice Address - Zip Code:16749
Practice Address - Country:US
Practice Address - Phone:814-887-5601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP009858224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant