Provider Demographics
NPI:1285307538
Name:CLARK, KAILA (OTD)
Entity type:Individual
Prefix:
First Name:KAILA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15801 W MONTECITO AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-7791
Mailing Address - Country:US
Mailing Address - Phone:763-258-6693
Mailing Address - Fax:
Practice Address - Street 1:9150 W INDIAN SCHOOL RD STE 105
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-2385
Practice Address - Country:US
Practice Address - Phone:480-787-5387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-008520225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist