Provider Demographics
NPI:1215257498
Name:CLARK, AMY (COTA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2770 JUNIPER DR
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72501-7801
Mailing Address - Country:US
Mailing Address - Phone:479-871-1130
Mailing Address - Fax:
Practice Address - Street 1:2770 JUNIPER DR
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-7801
Practice Address - Country:US
Practice Address - Phone:479-871-1130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A807224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant