Provider Demographics
NPI:1053482109
Name:CLEMENTS, JUDITH K (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:K
Last Name:CLEMENTS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 SW EMKAY DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1010
Mailing Address - Country:US
Mailing Address - Phone:541-389-3828
Mailing Address - Fax:541-388-5110
Practice Address - Street 1:1012 SW EMKAY DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1010
Practice Address - Country:US
Practice Address - Phone:541-389-3828
Practice Address - Fax:541-388-5110
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR604103T00000X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR13587Medicare UPIN
ORR0000TCHVDMedicare ID - Type Unspecified