Provider Demographics
NPI:1861609109
Name:CLERK, AUDREY MICHELE (MS,OTRL)
Entity type:Individual
Prefix:MISS
First Name:AUDREY
Middle Name:MICHELE
Last Name:CLERK
Suffix:
Gender:F
Credentials:MS,OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 WOLF DR
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-1731
Mailing Address - Country:US
Mailing Address - Phone:901-496-4231
Mailing Address - Fax:
Practice Address - Street 1:4443 N JOSEY LN
Practice Address - Street 2:SUITE 100
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4743
Practice Address - Country:US
Practice Address - Phone:972-939-3908
Practice Address - Fax:972-939-3939
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112040225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics