Provider Demographics
NPI:1003299017
Name:THELEN-CLEMMONS, THERESA AVILA (OTR/L)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:AVILA
Last Name:THELEN-CLEMMONS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 MESEROLE AVE APT 2D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11222-2675
Mailing Address - Country:US
Mailing Address - Phone:206-769-2098
Mailing Address - Fax:
Practice Address - Street 1:88 MESEROLE AVE APT 2D
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11222-2675
Practice Address - Country:US
Practice Address - Phone:206-769-2098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0197491225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics