Provider Demographics
NPI:1871844696
Name:CLARK, CHRISTINE M (PT)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:M
Other - Last Name:MANTIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:929 W HIGGINS RD
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60195-3203
Mailing Address - Country:US
Mailing Address - Phone:847-285-4200
Mailing Address - Fax:847-885-0130
Practice Address - Street 1:1002 COMMONS DR
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2539
Practice Address - Country:US
Practice Address - Phone:630-208-7831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016985225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216859246Medicare PIN