Provider Demographics
NPI:1013573161
Name:CLEMENTE, THERESE MIGNON (MFT)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:MIGNON
Last Name:CLEMENTE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5928 GRACIOSA DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90068-3031
Mailing Address - Country:US
Mailing Address - Phone:323-271-8387
Mailing Address - Fax:
Practice Address - Street 1:2550 HONOLULU AVE STE 107
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CA
Practice Address - Zip Code:91020-1859
Practice Address - Country:US
Practice Address - Phone:818-800-0279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT110257106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist