Basic Information
| Provider Information | |||||||||
| NPI: | 1124573274 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | DANIELLE | ||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3901 UNIVERSITY BLVD S | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322164312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043457336 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13910 FIVAY RD STE 6 | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346677130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278699479 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2016 | ||||||||
| LastUpdateDate: | 08/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | OTA12912 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.