Provider Demographics
NPI:1942411269
Name:CLARK, CHRISTINE MARY (MA ED)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARY
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA ED
Other - Prefix:
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Mailing Address - Street 1:455 THUNDERHEAD CANYON DR
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63011-1736
Mailing Address - Country:US
Mailing Address - Phone:636-458-5100
Mailing Address - Fax:
Practice Address - Street 1:4560 CLAYTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1502
Practice Address - Country:US
Practice Address - Phone:314-977-0175
Practice Address - Fax:314-977-0023
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist