Provider Demographics
NPI:1205045465
Name:CLEMENTE, BRIAN T
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:T
Last Name:CLEMENTE
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 1:2020 ALBATROSS ST APT 1
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-1839
Mailing Address - Country:US
Mailing Address - Phone:760-967-7082
Mailing Address - Fax:
Practice Address - Street 1:3142 VISTA WAY
Practice Address - Street 2:SUITE 207
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-3619
Practice Address - Country:US
Practice Address - Phone:760-967-7082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB31746103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical