MEDICARE: OLIVIA NORTILLO CLARK LSW, MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	150.114299	IL

General Provider Information

NPI Number	:	1073468401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA NORTILLO CLARK LSW, MSW

Provider Business Mailing Address
First Line	:	1445 CANTERBURY LN APT A208
Second Line	:
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-4457
Country	:	US
Telephone Number	:	847-212-7622
Fax Number	:

Provider Business Practice Location Address
First Line	:	1445 CANTERBURY LN APT A208
Second Line	:
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-4457
Country	:	US
Telephone Number	:	847-212-7622
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2026
Last Update Date	:	03/02/2026

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