MEDICARE: EMMA ELIZABETH CLARK MSW, PMH-C

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	104100000X	Social Worker		IL

General Provider Information

NPI Number	:	1114850138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMMA ELIZABETH CLARK MSW, PMH-C

Provider Business Mailing Address
First Line	:	908 E 53RD ST # 908-1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-4345
Country	:	US
Telephone Number	:	208-301-1971
Fax Number	:

Provider Business Practice Location Address
First Line	:	3759 N RAVENSWOOD AVE STE 226C
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-4088
Country	:	US
Telephone Number	:	312-487-1771
Fax Number	:

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

Provider Enumeration Date	:	06/08/2026
Last Update Date	:	06/15/2026

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