Provider Demographics
NPI:1093239758
Name:CLARK, MANDI LYNNE (NCSP)
Entity Type:Individual
Prefix:MRS
First Name:MANDI
Middle Name:LYNNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 MADELYN AVE
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3030
Mailing Address - Country:US
Mailing Address - Phone:309-776-3002
Mailing Address - Fax:
Practice Address - Street 1:310 S COAL ST
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:IL
Practice Address - Zip Code:62326-1209
Practice Address - Country:US
Practice Address - Phone:309-776-3002
Practice Address - Fax:309-776-3002
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1909260103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool