Provider Demographics
NPI:1013077361
Name:CLARK, MARY ANNE (PSYD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7358 N LINCOLN AVE STE 170
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-1710
Mailing Address - Country:US
Mailing Address - Phone:773-430-4601
Mailing Address - Fax:
Practice Address - Street 1:7358 N LINCOLN AVE STE 170
Practice Address - Street 2:
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-1710
Practice Address - Country:US
Practice Address - Phone:773-430-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-09
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212324Medicare PIN