MEDICARE: MRS. JULIE LYNN CLARK

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
1	225XP0200X	Pediatric Occupational Therapist	2000157767	MO

General Provider Information

NPI Number	:	1245372929
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JULIE LYNN CLARK

Provider Business Mailing Address
First Line	:	2446 FOREST LEAF PKWY
Second Line	:
City	:	WILDWOOD
State	:	MO
Zip	:	63011-1847
Country	:	US
Telephone Number	:	636-458-2584
Fax Number	:	636-458-2584

Provider Business Practice Location Address
First Line	:	2446 FOREST LEAF PKWY
Second Line	:
City	:	WILDWOOD
State	:	MO
Zip	:	63011-1847
Country	:	US
Telephone Number	:	636-458-2584
Fax Number	:	636-458-2584

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	07/08/2007

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