Healthcare Provider Details

I. General information

NPI: 1598135121
Provider Name (Legal Business Name): AMANDA CLARK OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2015
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13461 RAMONA AVE
CHINO CA
91710-5029
US

IV. Provider business mailing address

263 S CAMBRIDGE ST
ORANGE CA
92866-2065
US

V. Phone/Fax

Practice location:
  • Phone: 909-628-1201
  • Fax:
Mailing address:
  • Phone: 951-545-4044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number15657
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: