MEDICARE: MR. MICHAEL J CLARKE MA-CCC. SLP

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	235Z00000X	Speech-Language Pathologist	34-154	WI
2	235Z00000X	Speech-Language Pathologist	MC19430399P	IL
3	235Z00000X	Speech-Language Pathologist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	481943 CLA	OTHER	IL	UNITED HEALTHCARE
2	04927751	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1912064569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL J CLARKE MA-CCC. SLP

Provider Business Mailing Address
First Line	:	1412 LANDON AVE
Second Line	:
City	:	WINTHROP HARBOR
State	:	IL
Zip	:	60096-1844
Country	:	US
Telephone Number	:	847-361-5530
Fax Number	:	847-872-4817

Provider Business Practice Location Address
First Line	:	1412 LANDON AVE
Second Line	:
City	:	WINTHROP HARBOR
State	:	IL
Zip	:	60096-1844
Country	:	US
Telephone Number	:	847-361-5530
Fax Number	:	847-872-4817

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

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	04/20/2008

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Directions to “ MR. MICHAEL J CLARKE MA-CCC. SLP” Practice Location

Language	Start Address	Practice Location

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