1194870881 NPI number — MR. GEORGE WHITNEY CLEMENTS MSW

Table of content: MR. GEORGE WHITNEY CLEMENTS MSW (NPI 1194870881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194870881 NPI number — MR. GEORGE WHITNEY CLEMENTS MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLEMENTS
Provider First Name:
GEORGE
Provider Middle Name:
WHITNEY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
M

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:
1194870881
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 N. BROAD ST.
Provider Second Line Business Mailing Address:
MANKATO MENTAL HEALTH ASSOCIATES
Provider Business Mailing Address City Name:
MANKATO
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-345-4448
Provider Business Mailing Address Fax Number:
507-345-6761

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 N. BROAD ST.
Provider Second Line Business Practice Location Address:
MANKATO MENTAL HEALTH ASSOCIATES
Provider Business Practice Location Address City Name:
MANKATO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-345-4448
Provider Business Practice Location Address Fax Number:
507-345-6761
Provider Enumeration Date:
01/24/2007

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: 101YM0800X , with the licence number:  17134 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: LICSW17134 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 722391045623 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 138108 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 81G42CL . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP58819 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 061625700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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