Healthcare Provider Details

I. General information

NPI: 1619301546
Provider Name (Legal Business Name): COURTNEY CLARK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2013
Last Update Date: 08/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LAKE ST SUITE 201
OAK PARK IL
60301-1015
US

IV. Provider business mailing address

6230 W CUYLER AVE
CHICAGO IL
60634-1501
US

V. Phone/Fax

Practice location:
  • Phone: 773-766-7010
  • Fax:
Mailing address:
  • Phone: 773-544-2714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149008112
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: