Provider Demographics
NPI:1750417614
Name:CLARK, DAVETTE M
Entity type:Individual
Prefix:MS
First Name:DAVETTE
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:DAVETTE
Other - Middle Name:M
Other - Last Name:CLARK-JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4856 CASTLE DARGAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60478-5820
Mailing Address - Country:US
Mailing Address - Phone:708-957-8616
Mailing Address - Fax:708-957-8617
Practice Address - Street 1:4856 CASTLE DARGAN DR.
Practice Address - Street 2:
Practice Address - City:COUNTRY CLUB HILLS
Practice Address - State:IL
Practice Address - Zip Code:60478-5820
Practice Address - Country:US
Practice Address - Phone:708-957-8616
Practice Address - Fax:708-957-8617
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist