Provider Demographics
NPI:1457236424
Name:CLARK, KELCI
Entity type:Individual
Prefix:
First Name:KELCI
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 HIGGINS DR
Mailing Address - Street 2:
Mailing Address - City:HERMON
Mailing Address - State:ME
Mailing Address - Zip Code:04401-0239
Mailing Address - Country:US
Mailing Address - Phone:207-944-9395
Mailing Address - Fax:
Practice Address - Street 1:19 WHITE PINE RD STE C
Practice Address - Street 2:
Practice Address - City:HERMON
Practice Address - State:ME
Practice Address - Zip Code:04401-0258
Practice Address - Country:US
Practice Address - Phone:207-355-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-08
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOA4528224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant