Provider Demographics
NPI:1306658521
Name:CLARK, BERTHA DENISE (CFLE)
Entity type:Individual
Prefix:
First Name:BERTHA
Middle Name:DENISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:CFLE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 GULFSTREAM WAY
Mailing Address - Street 2:
Mailing Address - City:MASCOUTAH
Mailing Address - State:IL
Mailing Address - Zip Code:62258-2869
Mailing Address - Country:US
Mailing Address - Phone:907-240-3141
Mailing Address - Fax:
Practice Address - Street 1:1212 GULFSTREAM WAY
Practice Address - Street 2:
Practice Address - City:MASCOUTAH
Practice Address - State:IL
Practice Address - Zip Code:62258-2869
Practice Address - Country:US
Practice Address - Phone:907-240-3141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-24
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty