Provider Demographics
NPI:1558160846
Name:CLARK, ELLI BANES (LPC)
Entity type:Individual
Prefix:
First Name:ELLI
Middle Name:BANES
Last Name:CLARK
Suffix:
Gender:
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6991 DAGGERT RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARROLL
Mailing Address - State:IL
Mailing Address - Zip Code:61053-9132
Mailing Address - Country:US
Mailing Address - Phone:815-980-1153
Mailing Address - Fax:
Practice Address - Street 1:800 ROOSEVELT RD STE E220
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-5868
Practice Address - Country:US
Practice Address - Phone:815-980-1153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.021007101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional