Provider Demographics
NPI:1417079104
Name:CLARK, SHANNON (BS)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25225 SHANNON DR
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:IL
Mailing Address - Zip Code:60442-6203
Mailing Address - Country:US
Mailing Address - Phone:708-448-7423
Mailing Address - Fax:708-448-7843
Practice Address - Street 1:7440 W COLLEGE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1375
Practice Address - Country:US
Practice Address - Phone:708-448-7423
Practice Address - Fax:708-448-7843
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist