Provider Demographics
NPI:1912752072
Name:CLARK, JOANN
Entity type:Individual
Prefix:
First Name:JOANN
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3302 ASHFIELD LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-1204
Mailing Address - Country:US
Mailing Address - Phone:215-681-8078
Mailing Address - Fax:
Practice Address - Street 1:2600 WAYLAND RD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:PA
Practice Address - Zip Code:19312-2307
Practice Address - Country:US
Practice Address - Phone:610-325-4976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC019421225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist