Provider Demographics
NPI:1699431791
Name:TEALL, CLARA (MT-BC, NMT)
Entity type:Individual
Prefix:
First Name:CLARA
Middle Name:
Last Name:TEALL
Suffix:
Gender:F
Credentials:MT-BC, NMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 W FARGO AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-1768
Mailing Address - Country:US
Mailing Address - Phone:734-476-9712
Mailing Address - Fax:
Practice Address - Street 1:401 E PROSPECT AVE STE 208
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-3396
Practice Address - Country:US
Practice Address - Phone:734-476-9712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
16091225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
16091OtherCERTIFICATION BOARD FOR MUSIC THERAPISTS