MEDICARE: MISS SHELEAH CLARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	32001852A	IN

General Provider Information

NPI Number	:	1093019473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS SHELEAH CLARK

Provider Business Mailing Address
First Line	:	3108 CANTERBURY BLVD APT 6
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46835-3228
Country	:	US
Telephone Number	:	260-418-5419
Fax Number	:

Provider Business Practice Location Address
First Line	:	3108 CANTERBURY BLVD APT 6
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46835-3228
Country	:	US
Telephone Number	:	260-418-5419
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/29/2010
Last Update Date	:	12/29/2010

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Directions to “ MISS SHELEAH CLARK ” Practice Location

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