Provider Demographics
NPI:1346923422
Name:CLARK, KELLY M (MSW LSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSW LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10168 HANOVER AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-8160
Mailing Address - Country:US
Mailing Address - Phone:847-338-3850
Mailing Address - Fax:
Practice Address - Street 1:1375 E WOODFIELD RD STE 220
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-6068
Practice Address - Country:US
Practice Address - Phone:847-338-3850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker