Provider Demographics
NPI:1194700336
Name:CLARKE, DEBORAH R (OT)
Entity type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:R
Last Name:CLARKE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1397
Mailing Address - Street 2:310 NORTH 9TH STREET
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58502-1397
Mailing Address - Country:US
Mailing Address - Phone:701-530-8742
Mailing Address - Fax:
Practice Address - Street 1:310 NORTH 9TH STREET
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58502
Practice Address - Country:US
Practice Address - Phone:701-530-8742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ729225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ747983Medicaid
AZ73003Medicare ID - Type Unspecified
AZ747983Medicaid