MEDICARE: VIRGINIA H CLARK OTR, CHT

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	225XH1200X	Hand Occupational Therapist	OT642	FL

General Provider Information

NPI Number	:	1497975387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIRGINIA H CLARK OTR, CHT

Provider Business Mailing Address
First Line	:	5847 21ST AVE W
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34209-5641
Country	:	US
Telephone Number	:	941-792-3134
Fax Number	:	941-792-2524

Provider Business Practice Location Address
First Line	:	5847 21ST AVE W
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34209-5641
Country	:	US
Telephone Number	:	941-792-3134
Fax Number	:	941-792-2524

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

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	07/08/2007

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