Healthcare Provider Details

I. General information

NPI: 1629704630
Provider Name (Legal Business Name): SYDNE JUSTINE CLARK M.S., OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2022
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 E 18TH ST
OWENSBORO KY
42303-3751
US

IV. Provider business mailing address

122 E 18TH ST
OWENSBORO KY
42303-3751
US

V. Phone/Fax

Practice location:
  • Phone: 270-926-2212
  • Fax: 270-926-2215
Mailing address:
  • Phone: 270-926-2212
  • Fax: 270-926-2215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number276408
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number276408
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: