Basic Information
Provider Information
NPI: 1003008194
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CLARK
FirstName: CINDY
MiddleName:  
NamePrefix: MRS.
NameSuffix:  
Credential: COTA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 10420 BARTON ST
Address2:  
City: OVERLAND PARK
State: KS
PostalCode: 662143009
CountryCode: US
TelephoneNumber: 9133222987
FaxNumber:  
Practice Location
Address1: 10420 BARTON ST
Address2:  
City: OVERLAND PARK
State: KS
PostalCode: 662143009
CountryCode: US
TelephoneNumber: 9133222987
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/13/2007
LastUpdateDate: 08/13/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
224Z00000X004730MOY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant 
224Z00000X18-00598KSN Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant 

No ID Information.


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