Provider Demographics
NPI:1649383902
Name:CLARK, DAVID CHARLES (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:CHARLES
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 ASH ST
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:IL
Mailing Address - Zip Code:60093-2102
Mailing Address - Country:US
Mailing Address - Phone:312-543-9987
Mailing Address - Fax:847-501-3857
Practice Address - Street 1:552 LINCOLN AVE STE 205
Practice Address - Street 2:
Practice Address - City:WINNETKA
Practice Address - State:IL
Practice Address - Zip Code:60093-2353
Practice Address - Country:US
Practice Address - Phone:312-543-9987
Practice Address - Fax:847-501-3857
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL727310Medicare ID - Type UnspecifiedPROVIDER NUMBER