MEDICARE: ALYSSA 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
1	225X00000X	Occupational Therapist	OT.0004991	CO

General Provider Information

NPI Number	:	1407376288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALYSSA CLARK OTR/L

Provider Business Mailing Address
First Line	:	8301 DETROIT AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44102-1859
Country	:	US
Telephone Number	:	216-791-3800
Fax Number	:

Provider Business Practice Location Address
First Line	:	8301 DETROIT AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44102-1859
Country	:	US
Telephone Number	:	216-791-3800
Fax Number	:

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

Provider Enumeration Date	:	06/22/2017
Last Update Date	:	11/20/2023

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