Provider Demographics
NPI:1093803058
Name:CLARK LAY, COLLEEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:
Last Name:CLARK LAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2556 ROBERT DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:IL
Mailing Address - Zip Code:60538-3351
Mailing Address - Country:US
Mailing Address - Phone:630-892-4824
Mailing Address - Fax:
Practice Address - Street 1:9620 US ROUTE 34
Practice Address - Street 2:SUITE E
Practice Address - City:YORKVILLE
Practice Address - State:IL
Practice Address - Zip Code:60560-1394
Practice Address - Country:US
Practice Address - Phone:630-688-0289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490109851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical