Basic Information
| Provider Information | |||||||||
| NPI: | 1720447717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | LINDSAY | ||||||||
| MiddleName: | MARIE-PORTREY | ||||||||
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| OtherLastName: | PORTREY | ||||||||
| OtherFirstName: | LINDSAY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8542 W GRAND RIVER AVE | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481162326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344494649 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8542 W GRAND RIVER AVE | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481162326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344494649 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2016 | ||||||||
| LastUpdateDate: | 10/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5201009312 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.