Healthcare Provider Details

I. General information

NPI: 1942042643
Provider Name (Legal Business Name): CLARENCE POE OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2024
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1057 CHADWICK CT
AURORA IL
60502-9323
US

IV. Provider business mailing address

1057 CHADWICK CT
AURORA IL
60502-9323
US

V. Phone/Fax

Practice location:
  • Phone: 630-800-2444
  • Fax: 773-904-2361
Mailing address:
  • Phone: 630-800-2444
  • Fax: 773-904-2361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.016880
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: