Provider Demographics
NPI:1467634972
Name:M. A. CLARK, INC
Entity Type:Organization
Organization Name:M. A. CLARK, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:773-478-8145
Mailing Address - Street 1:4055 W PETERSON AVE
Mailing Address - Street 2:201
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-6182
Mailing Address - Country:US
Mailing Address - Phone:773-478-8145
Mailing Address - Fax:773-478-8105
Practice Address - Street 1:4055 W PETERSON AVE
Practice Address - Street 2:201
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-6182
Practice Address - Country:US
Practice Address - Phone:773-478-8145
Practice Address - Fax:773-478-8105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212324Medicare PIN