Provider Demographics
NPI:1174515829
Name:CLARK, KATHLEEN A (PT)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:A
Other - Last Name:WITTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:P.O. BOX 274
Mailing Address - Street 2:
Mailing Address - City:SUGAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60554-5031
Mailing Address - Country:US
Mailing Address - Phone:630-466-9240
Mailing Address - Fax:630-466-9248
Practice Address - Street 1:2700 KESLINGER ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4645
Practice Address - Country:US
Practice Address - Phone:630-262-2633
Practice Address - Fax:630-262-2643
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070011591225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK15643Medicare ID - Type UnspecifiedWOL INDIVIDUAL PROVIDER #