Basic Information
| Provider Information | |||||||||
| NPI: | 1871844696 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MANTIS | ||||||||
| OtherFirstName: | CHRISTINE | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 929 W HIGGINS RD | ||||||||
| Address2: | |||||||||
| City: | SCHAUMBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601953203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472854200 | ||||||||
| FaxNumber: | 8478850130 | ||||||||
| Practice Location | |||||||||
| Address1: | 1002 COMMONS DR | ||||||||
| Address2: | |||||||||
| City: | GENEVA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601342539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302087831 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2012 | ||||||||
| LastUpdateDate: | 06/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070016985 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.