Provider Demographics
NPI:1881900470
Name:CLARK, GLORIA JEAN (OT)
Entity type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:JEAN
Last Name:CLARK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:DR
Other - First Name:GLORIA
Other - Middle Name:FROLEK
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OT
Mailing Address - Street 1:23878 SCENIC VIEW DR
Mailing Address - Street 2:
Mailing Address - City:ADEL
Mailing Address - State:IA
Mailing Address - Zip Code:50003-8509
Mailing Address - Country:US
Mailing Address - Phone:515-993-5026
Mailing Address - Fax:
Practice Address - Street 1:23878 SCENIC VIEW DR
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:IA
Practice Address - Zip Code:50003-8509
Practice Address - Country:US
Practice Address - Phone:515-993-5026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-20
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAOOO78225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist