Provider Demographics
NPI:1962701482
Name:CLARK, TERESA MAY (MSOT, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:MAY
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9501 HIGHWAY 662
Mailing Address - Street 2:
Mailing Address - City:MACEO
Mailing Address - State:KY
Mailing Address - Zip Code:42355-9741
Mailing Address - Country:US
Mailing Address - Phone:270-302-2216
Mailing Address - Fax:
Practice Address - Street 1:815 TRIPLETT ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3564
Practice Address - Country:US
Practice Address - Phone:270-683-4517
Practice Address - Fax:270-852-1491
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY184517OtherMEDICARE
KY45118379Medicaid