1104320779 NPI number — SAVANNAH JO CLEMONS LPCC

Table of content: SAVANNAH JO CLEMONS LPCC (NPI 1104320779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104320779 NPI number — SAVANNAH JO CLEMONS LPCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLEMONS
Provider First Name:
SAVANNAH
Provider Middle Name:
JO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPCC
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:
1104320779
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1080
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURKESVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42717-1080
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-864-1472
Provider Business Mailing Address Fax Number:
270-864-1693

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 WEST UNION ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MUNFORDVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42765-8909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-435-0900
Provider Business Practice Location Address Fax Number:
270-858-4029
Provider Enumeration Date:
03/20/2018

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: 101YP2500X , with the licence number:  288209 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YP2500X , with the licence number: 172500 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 172500 . This is a "KENTUCKY BOARD OF LICENSED PROFESSIONAL COUNSELORS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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