Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XG0600X | Occupational Therapist - Gerontology | 5857 | CA |
NPI | 1437548062 |
---|---|
Provider Name | Brian Clark |
First Address | Rocklin, CA 95677-4487 |
Second Address | Rocklin, CA 95677-4487 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/01/2015 |
Last Update Date | 20/01/2015 |