Healthcare Provider Details

I. General information

NPI: 1902710726
Provider Name (Legal Business Name): SHOSHANA CLARK OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHONA CLARK

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3329 E BELL RD STE A5
PHOENIX AZ
85032-2757
US

IV. Provider business mailing address

1521 W MENADOTA DR
PHOENIX AZ
85027-4225
US

V. Phone/Fax

Practice location:
  • Phone: 602-258-4788
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTH-010505
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: