1720077670 NPI number — DR. BRENDA SUE CLEMENTS DPT, MTC

Table of content: DR. BRENDA SUE CLEMENTS DPT, MTC (NPI 1720077670)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720077670 NPI number — DR. BRENDA SUE CLEMENTS DPT, MTC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLEMENTS
Provider First Name:
BRENDA
Provider Middle Name:
SUE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPT, MTC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720077670
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1827 HARRISON AVE
Provider Second Line Business Mailing Address:
BUILDING 4
Provider Business Mailing Address City Name:
PANAMA CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32405-7605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-872-7022
Provider Business Mailing Address Fax Number:
850-872-7021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1827 HARRISON AVE
Provider Second Line Business Practice Location Address:
BUILDING 4
Provider Business Practice Location Address City Name:
PANAMA CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32405-7605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-872-7022
Provider Business Practice Location Address Fax Number:
850-872-7021
Provider Enumeration Date:
10/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT19943 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2288818 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: Y909J . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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