Provider Demographics
NPI:1063071942
Name:CLARK, MICHELLE T (OTR)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:T
Last Name:CLARK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:889 N AURORA RD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:OH
Mailing Address - Zip Code:44202-9537
Mailing Address - Country:US
Mailing Address - Phone:330-954-7177
Mailing Address - Fax:330-995-8279
Practice Address - Street 1:889 N AURORA RD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:OH
Practice Address - Zip Code:44202-9537
Practice Address - Country:US
Practice Address - Phone:330-954-7177
Practice Address - Fax:330-995-8279
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT002596225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist