Individual
THERESA CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
C.O.T.A.
Contact information
Practice address
2300 GREAT LAKES DR, DYER, IN 46311-1917
(219) 322-3555
Mailing address
612 215TH ST, DYER, IN 46311-1512
(219) 864-8826
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
32001147A
IN
Other
Enumeration date
09/12/2008
Last updated
09/12/2008
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