Provider Demographics
NPI:1447471735
Name:CLARK, TRACI D (COTA)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:D
Last Name:CLARK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5218 S MOUNT PLEASANT RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371-7201
Mailing Address - Country:US
Mailing Address - Phone:260-726-2433
Mailing Address - Fax:
Practice Address - Street 1:910 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47320-1530
Practice Address - Country:US
Practice Address - Phone:765-789-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant