Provider Demographics
NPI:1215176664
Name:CLARK, MICHELLE ANN (LOTR)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 C DEES RD
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-8935
Mailing Address - Country:US
Mailing Address - Phone:404-433-1208
Mailing Address - Fax:
Practice Address - Street 1:457 C DEES RD
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-8935
Practice Address - Country:US
Practice Address - Phone:404-433-1208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z11886225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist