Provider Demographics
NPI:1053625764
Name:CLARK, STACY (PHD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 E WASHINGTON ST
Mailing Address - Street 2:1791
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1708
Mailing Address - Country:US
Mailing Address - Phone:773-263-0003
Mailing Address - Fax:
Practice Address - Street 1:25 E WASHINGTON ST
Practice Address - Street 2:1719
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1708
Practice Address - Country:US
Practice Address - Phone:773-263-0003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-05
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007953103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical