MEDICARE: DONNA REE CLARK-WHITE

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	222Q00000X	Developmental Therapist
2	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1093479818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA REE CLARK-WHITE

Provider Business Mailing Address
First Line	:	6136 S EBERHART AVE APT 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60637-6124
Country	:	US
Telephone Number	:	773-449-9961
Fax Number	:

Provider Business Practice Location Address
First Line	:	1336 E 89TH PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-7004
Country	:	US
Telephone Number	:	773-449-9961
Fax Number	:

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

Provider Enumeration Date	:	10/27/2021
Last Update Date	:	08/14/2024

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Directions to “ DONNA REE CLARK-WHITE ” Practice Location

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