MEDICARE: MS. CAROL CLARK CADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	26825	IL

General Provider Information

NPI Number	:	1265938302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAROL CLARK CADC

Provider Business Mailing Address
First Line	:	222 S JEFFERSON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60661-5603
Country	:	US
Telephone Number	:	312-441-9009
Fax Number	:	312-441-9019

Provider Business Practice Location Address
First Line	:	2311 E 98TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-4842
Country	:	US
Telephone Number	:	773-785-4955
Fax Number	:	773-785-9011

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2018
Last Update Date	:	04/05/2018

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