Provider Demographics
NPI:1053418848
Name:CLARK, LUCRETHIA (OTR/L)
Entity type:Individual
Prefix:
First Name:LUCRETHIA
Middle Name:
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 1:2861 NW 171ST ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-4444
Mailing Address - Country:US
Mailing Address - Phone:305-623-4759
Mailing Address - Fax:305-623-4759
Practice Address - Street 1:12545 ORANGE DR
Practice Address - Street 2:SUITE 502
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33330-4306
Practice Address - Country:US
Practice Address - Phone:954-236-9415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 11982225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist