Provider Demographics
NPI:1700278447
Name:CLARK, ANGELLA (LMT)
Entity Type:Individual
Prefix:
First Name:ANGELLA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 N ROCK RUN DR
Mailing Address - Street 2:APT. D2
Mailing Address - City:CREST HILL
Mailing Address - State:IL
Mailing Address - Zip Code:60403-8322
Mailing Address - Country:US
Mailing Address - Phone:708-341-2026
Mailing Address - Fax:
Practice Address - Street 1:23819 W MILL ST
Practice Address - Street 2:SUITE 7
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-3457
Practice Address - Country:US
Practice Address - Phone:815-408-0071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227005736225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist