Provider Demographics
NPI:1003585266
Name:CLYSDALE, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:CLYSDALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 N HALSTED ST APT 1314
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-1375
Mailing Address - Country:US
Mailing Address - Phone:651-308-7291
Mailing Address - Fax:
Practice Address - Street 1:420 W FRONTAGE RD STE 200
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3046
Practice Address - Country:US
Practice Address - Phone:847-784-9115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL56014281225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics