Provider Demographics
NPI:1114088895
Name:CLEMENTS, ERIC L
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:L
Last Name:CLEMENTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6846 S CANTON AVE
Mailing Address - Street 2:SUITE 501
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3412
Mailing Address - Country:US
Mailing Address - Phone:918-745-0095
Mailing Address - Fax:918-745-0190
Practice Address - Street 1:6846 S CANTON AVE
Practice Address - Street 2:SUITE 501
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3412
Practice Address - Country:US
Practice Address - Phone:918-745-0095
Practice Address - Fax:918-745-0190
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1673101YP2500X
OK758106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional