Provider Demographics
NPI:1639370984
Name:CLARK, MIKE A (OT)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23235 S VOLBRECHT RD
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:IL
Mailing Address - Zip Code:60417-1789
Mailing Address - Country:US
Mailing Address - Phone:708-757-5362
Mailing Address - Fax:
Practice Address - Street 1:444 N WELLS ST STE 304
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-4593
Practice Address - Country:US
Practice Address - Phone:708-757-5362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31001679A225X00000X
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist