Provider Demographics
NPI:1063628048
Name:CLEMENS, PENNY SUE (OTA)
Entity Type:Individual
Prefix:MS
First Name:PENNY
Middle Name:SUE
Last Name:CLEMENS
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31584 AGOURA RD # 3 BLD 10
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-4442
Mailing Address - Country:US
Mailing Address - Phone:818-631-8541
Mailing Address - Fax:
Practice Address - Street 1:31584 AGOURA RD # 3 BLD 10
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-4442
Practice Address - Country:US
Practice Address - Phone:818-631-8541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOTA 39OtherCOTA