Provider Demographics
NPI:1396104485
Name:CLARK, CHRYSTAL C (DPT)
Entity type:Individual
Prefix:
First Name:CHRYSTAL
Middle Name:C
Last Name:CLARK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:630-575-6250
Mailing Address - Fax:630-575-7450
Practice Address - Street 1:5250 HIGHWAY 78 STE 200
Practice Address - Street 2:
Practice Address - City:SACHSE
Practice Address - State:TX
Practice Address - Zip Code:75048-4253
Practice Address - Country:US
Practice Address - Phone:972-244-4270
Practice Address - Fax:972-476-9903
Is Sole Proprietor?:No
Enumeration Date:2016-02-17
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX1271135174400000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist