Basic Information
| Provider Information | |||||||||
| NPI: | 1871689802 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | PAULETTE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OCCUPATIONAL THERAPI | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | PATRICIA | ||||||||
| OtherMiddleName: | PAULETTE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OT OCCUPATIONAL THER | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 342 VIRGINIA AVENUE | ||||||||
| Address2: | HEARTLAND REHABILITATION SERVICES OF VIRGINIA INC | ||||||||
| City: | WYTHEVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762286200 | ||||||||
| FaxNumber: | 2762289175 | ||||||||
| Practice Location | |||||||||
| Address1: | 342 VIRGINIA AVENUE | ||||||||
| Address2: | HEARTLAND REHABILITATION SERVICES OF VIRGINIA INC | ||||||||
| City: | WYTHEVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762286200 | ||||||||
| FaxNumber: | 2762289175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 0119003556 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.