Provider Demographics
NPI:1134571607
Name:CLARKE, GINA KAY
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:KAY
Last Name:CLARKE
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 1:540 MILL ST
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IL
Mailing Address - Zip Code:62379-1731
Mailing Address - Country:US
Mailing Address - Phone:309-431-1982
Mailing Address - Fax:
Practice Address - Street 1:540 MILL ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IL
Practice Address - Zip Code:62379-1731
Practice Address - Country:US
Practice Address - Phone:217-617-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-08
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0813581041C0700X
IL1490162761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical