Provider Demographics
NPI:1053343681
Name:CLARK, CAROL SHELBY (OT)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:SHELBY
Last Name:CLARK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:926 LAWN VIEW LN
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37064-5566
Mailing Address - Country:US
Mailing Address - Phone:901-299-0669
Mailing Address - Fax:615-595-0812
Practice Address - Street 1:1647 MALLORY LN
Practice Address - Street 2:SUITE 103
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-2909
Practice Address - Country:US
Practice Address - Phone:615-661-5437
Practice Address - Fax:615-277-2838
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3421225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics