Provider Demographics
NPI:1730259342
Name:CLARK, KRISTY MAY (OT)
Entity type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:MAY
Last Name:CLARK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MRS
Other - First Name:KRISTY
Other - Middle Name:MAY
Other - Last Name:DEJNAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:144 CANAL STREET
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03064
Mailing Address - Country:US
Mailing Address - Phone:603-882-6333
Mailing Address - Fax:603-889-5460
Practice Address - Street 1:144 CANAL STREET
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03064
Practice Address - Country:US
Practice Address - Phone:603-882-6333
Practice Address - Fax:603-889-5460
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1582225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH13Y003886NH01OtherBCBS
NH272746OtherCIGNA
NH561822OtherAETNA
NH626514OtherHARVARD PILGRIM
NH761242OtherTUFTS
NH99560056Medicaid