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NPI Code Detail

MEDICARE: MRS. GRETCHEN MARIE CLARK OTR/L

MEDICARE: MRS. GRETCHEN MARIE CLARK OTR/L
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225X00000XOccupational TherapistOT 12485FL

General Provider Information

NPI Number : 1013288778
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. GRETCHEN MARIE CLARK OTR/L
Provider Business Mailing Address
First Line : 4020 GREENLEAF DR
Second Line :
City : KISSIMMEE
State : FL
Zip : 34744-9150
Country : US
Telephone Number : 856-904-8521
Fax Number :
Provider Business Practice Location Address
First Line : 15204 W COLONIAL DR
Second Line :
City : WINTER GARDEN
State : FL
Zip : 34787-6042
Country : US
Telephone Number : 407-877-2394
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/25/2012
Last Update Date : 01/25/2012

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