Provider Demographics
NPI:1912064569
Name:CLARKE, MICHAEL J (MA-CCC SLP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:CLARKE
Suffix:
Gender:M
Credentials:MA-CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 LANDON AVE
Mailing Address - Street 2:
Mailing Address - City:WINTHROP HARBOR
Mailing Address - State:IL
Mailing Address - Zip Code:60096-1844
Mailing Address - Country:US
Mailing Address - Phone:847-361-5530
Mailing Address - Fax:847-872-4817
Practice Address - Street 1:1412 LANDON AVE
Practice Address - Street 2:
Practice Address - City:WINTHROP HARBOR
Practice Address - State:IL
Practice Address - Zip Code:60096-1844
Practice Address - Country:US
Practice Address - Phone:847-361-5530
Practice Address - Fax:847-872-4817
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34-154235Z00000X
ILMC19430399P235Z00000X
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL481943 CLAOtherUNITED HEALTHCARE
IL04927751OtherBLUE CROSS BLUE SHIELD
IL$$$$$$$$$001Medicaid
IL04927751OtherBLUE CROSS BLUE SHIELD