Provider Demographics
NPI:1003023714
Name:CLAVELLI, SANDRA ELLEN JOHNSON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:ELLEN JOHNSON
Last Name:CLAVELLI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:SANDRA
Other - Middle Name:ELLEN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:2699 HOBSON RD APT 6
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-1550
Mailing Address - Country:US
Mailing Address - Phone:847-636-7637
Mailing Address - Fax:
Practice Address - Street 1:420 W. GRAND AVE
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046
Practice Address - Country:US
Practice Address - Phone:847-245-6469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL71007250103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical