Provider Demographics
NPI:1790575777
Name:CLARK, ANDREA NICOLE
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:NICOLE
Last Name:CLARK
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 1:8040 S MERRILL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-1154
Mailing Address - Country:US
Mailing Address - Phone:708-870-5284
Mailing Address - Fax:
Practice Address - Street 1:8550 S HARLEM AVE STE G
Practice Address - Street 2:
Practice Address - City:BRIDGEVIEW
Practice Address - State:IL
Practice Address - Zip Code:60455-1775
Practice Address - Country:US
Practice Address - Phone:630-387-9305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional