Provider Demographics
NPI:1205281144
Name:CLARK, MARIE KAYE
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:KAYE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:KAYE
Other - Last Name:LEATHERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7900 REEDS RD
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66208-4965
Mailing Address - Country:US
Mailing Address - Phone:913-530-0483
Mailing Address - Fax:
Practice Address - Street 1:8340 MISSION RD STE B
Practice Address - Street 2:
Practice Address - City:PRAIRIE VILLAGE
Practice Address - State:KS
Practice Address - Zip Code:66206-1355
Practice Address - Country:US
Practice Address - Phone:913-213-3531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-28
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-03575225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics