1609966415 NPI number — MR. TIMOTHY LEW CLARK LCSW LCPC CSADC SAP

Table of content: MR. TIMOTHY LEW CLARK LCSW LCPC CSADC SAP (NPI 1609966415)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609966415 NPI number — MR. TIMOTHY LEW CLARK LCSW LCPC CSADC SAP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
TIMOTHY
Provider Middle Name:
LEW
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW LCPC CSADC SAP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609966415
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
880 LEE STREET
Provider Second Line Business Mailing Address:
SUITE 208
Provider Business Mailing Address City Name:
DES PLAINES
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-298-8830
Provider Business Mailing Address Fax Number:
847-298-8831

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
880 LEE STREET
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
DES PLAINES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-298-8830
Provider Business Practice Location Address Fax Number:
847-298-8831
Provider Enumeration Date:
10/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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