Provider Demographics
NPI:1255918637
Name:CLARK-KEENE, KATHARINE COURTNEY
Entity type:Individual
Prefix:MRS
First Name:KATHARINE
Middle Name:COURTNEY
Last Name:CLARK-KEENE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 W STONEGATE BLVD STE 101-2109
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-1045
Mailing Address - Country:US
Mailing Address - Phone:331-241-6485
Mailing Address - Fax:
Practice Address - Street 1:3400 W STONEGATE BLVD STE 101-2109
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-1045
Practice Address - Country:US
Practice Address - Phone:331-241-6485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILBACB514668227800000X
IL1-21-48826103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified