Healthcare Provider Details

I. General information

NPI: 1114850138
Provider Name (Legal Business Name): EMMA ELIZABETH CLARK MSW, PMH-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3759 N RAVENSWOOD AVE STE 226C
CHICAGO IL
60613-4088
US

IV. Provider business mailing address

908 E 53RD ST # 908-1
CHICAGO IL
60615-4345
US

V. Phone/Fax

Practice location:
  • Phone: 312-487-1771
  • Fax:
Mailing address:
  • Phone: 208-301-1971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: