Provider Demographics
NPI:1174750038
Name:CLARK, MELINDA VOGUIT (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:VOGUIT
Last Name:CLARK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4829 INNISBROOK CT S
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:FL
Mailing Address - Zip Code:32033-2067
Mailing Address - Country:US
Mailing Address - Phone:904-374-1414
Mailing Address - Fax:
Practice Address - Street 1:4829 INNISBROOK CT S
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:FL
Practice Address - Zip Code:32033-2067
Practice Address - Country:US
Practice Address - Phone:904-374-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT13589225X00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001078200Medicaid
FL001078300Medicaid