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General NPI Number Information
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NPI Number | 1639370984
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Entity Type | Individual
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Provider Name | MIKE A CLARK OT
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Gender | Male
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Dates
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Enumeration Date | 05/31/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 444 N WELLS ST STE 304
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City | CHICAGO
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State | IL
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Zip | 60610-4593
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Country | US
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Telephone | 708-757-5362
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Fax |
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Provider Business Mailing Address
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Address Line | 23235 S VOLBRECHT RD
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City | CRETE
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State | IL
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Zip | 60417-1789
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Country | US
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Telephone | 708-757-5362
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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 | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 31001679A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State | IL
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