Provider Demographics
NPI:1366471781
Name:CLARKE, CARRIE ELLEN (MSW)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:ELLEN
Last Name:CLARKE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 W CLARENDON ST
Mailing Address - Street 2:
Mailing Address - City:PROSPECT HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60070-1403
Mailing Address - Country:US
Mailing Address - Phone:847-394-3961
Mailing Address - Fax:
Practice Address - Street 1:3001 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-3048
Practice Address - Country:US
Practice Address - Phone:224-610-1354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI006745-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI006745-123Medicare UPIN