Provider Demographics
NPI:1154130631
Name:ELLENBURG, CLARA ANN (COTA/L)
Entity type:Individual
Prefix:MS
First Name:CLARA
Middle Name:ANN
Last Name:ELLENBURG
Suffix:
Gender:F
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 1:2578 GREENE 721 RD
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-7909
Mailing Address - Country:US
Mailing Address - Phone:870-335-0257
Mailing Address - Fax:
Practice Address - Street 1:447 S COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:AR
Practice Address - Zip Code:72370-4207
Practice Address - Country:US
Practice Address - Phone:870-563-0199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A2084224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant