Provider Demographics
NPI:1831661958
Name:CLARK, KENDRA
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 HILLS HEALTHCARE CENTER
Mailing Address - Street 2:455 E MAIN ST.
Mailing Address - City:EAST DUNDEE
Mailing Address - State:IL
Mailing Address - Zip Code:60118
Mailing Address - Country:US
Mailing Address - Phone:847-428-2273
Mailing Address - Fax:
Practice Address - Street 1:455 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST DUNDEE
Practice Address - State:IL
Practice Address - Zip Code:60118-1529
Practice Address - Country:US
Practice Address - Phone:847-428-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-31
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL171M00000XMedicaid