Provider Demographics
NPI:1194409136
Name:CLARK, THERESA RENEE (COTA/L)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:RENEE
Last Name:CLARK
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 1:3067 DAVENPORT WAY
Mailing Address - Street 2:
Mailing Address - City:PENNSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18073-1286
Mailing Address - Country:US
Mailing Address - Phone:267-441-6179
Mailing Address - Fax:
Practice Address - Street 1:4000 FOXHOUND DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE HILL
Practice Address - State:PA
Practice Address - Zip Code:19444-1014
Practice Address - Country:US
Practice Address - Phone:215-402-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP010353224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant