Healthcare Provider Details

I. General information

NPI: 1750964706
Provider Name (Legal Business Name): BAILEY CLARK COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 E MAIN ST
LAKE BUTLER FL
32054-1353
US

IV. Provider business mailing address

692 NE STATE ROAD 16
STARKE FL
32091
US

V. Phone/Fax

Practice location:
  • Phone: 386-496-2323
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA17741
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: