Provider Demographics
NPI:1023370558
Name:CLEMENS, TERRI (LAC, MSOM)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:CLEMENS
Suffix:
Gender:F
Credentials:LAC, MSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 DEMPSTER ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1003
Mailing Address - Country:US
Mailing Address - Phone:847-491-1122
Mailing Address - Fax:847-570-6083
Practice Address - Street 1:1818 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-1003
Practice Address - Country:US
Practice Address - Phone:847-491-1122
Practice Address - Fax:847-570-6083
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198-000240171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist