Provider Demographics
NPI:1255464855
Name:CLEMONS, SUSAN D (PHD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:CLEMONS
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 1:2013 N GREEN ACRES RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703
Mailing Address - Country:US
Mailing Address - Phone:479-444-3354
Mailing Address - Fax:479-555-6770
Practice Address - Street 1:2013 N GREEN ACRES RD
Practice Address - Street 2:SUITE C
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-444-3354
Practice Address - Fax:479-555-6770
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR06-22P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL20-5113370OtherTAX IDENTIFICATION NUMBER