Healthcare Provider Details

I. General information

NPI: 1790830669
Provider Name (Legal Business Name): DEBORAH CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 DUNN AVE
DAYTONA BEACH FL
32114-2405
US

IV. Provider business mailing address

2244 JUANITA DR
NEW SMYRNA BEACH FL
32168-8491
US

V. Phone/Fax

Practice location:
  • Phone: 386-255-4568
  • Fax:
Mailing address:
  • Phone: 386-423-5187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number403
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: