Provider Demographics
NPI:1083176580
Name:SMITH CLEMONS, SONJA REGINA
Entity Type:Individual
Prefix:
First Name:SONJA
Middle Name:REGINA
Last Name:SMITH CLEMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11725 MILES AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-5469
Mailing Address - Country:US
Mailing Address - Phone:216-713-4162
Mailing Address - Fax:
Practice Address - Street 1:11725 MILES AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-5469
Practice Address - Country:US
Practice Address - Phone:216-713-4162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.169975101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCDCA.169975OtherLICENSE