Provider Demographics
NPI:1457690844
Name:CLARK, KEISHA ANN
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:ANN
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 1:3711 S VINCENNES AVE
Mailing Address - Street 2:UNIT 614
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-1882
Mailing Address - Country:US
Mailing Address - Phone:309-721-8831
Mailing Address - Fax:
Practice Address - Street 1:3711 S VINCENNES AVE
Practice Address - Street 2:UNIT 614
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-1882
Practice Address - Country:US
Practice Address - Phone:309-721-8831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist