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General NPI Number Information
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NPI Number | 1306645106
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Entity Type | Individual
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Provider Name | MR. CLARK A BRAY
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Gender | Male
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Dates
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Enumeration Date | 03/12/2025
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Last Update Date | 03/12/2025
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Provider Practice Location Address
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Address Line | 5537 N CLARK ST, 2ND FLOOR
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City | CHICAGO
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State | IL
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Zip | 60640
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Country | US
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Telephone | 773-219-1107
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Fax |
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Provider Business Mailing Address
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Address Line | 3440 W POTOMAC AVE UNIT 1
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City | CHICAGO
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State | IL
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Zip | 60651-2329
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Country | US
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Telephone | 603-667-0822
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 150.112290
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License Number State | IL
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