Provider Demographics
NPI:1053638155
Name:CLARK, CHRISTIE M (OT)
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:CHRISTIE
Other - Middle Name:M
Other - Last Name:BENEDICT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:503 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401
Mailing Address - Country:US
Mailing Address - Phone:217-347-1243
Mailing Address - Fax:217-347-1558
Practice Address - Street 1:503 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401
Practice Address - Country:US
Practice Address - Phone:217-347-1243
Practice Address - Fax:217-347-1558
Is Sole Proprietor?:No
Enumeration Date:2010-04-28
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056004595225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist