Provider Demographics
NPI:1346346525
Name:CLEMONS, DOLORES CANCINO (LCSW-BACS-MVF-CSW)
Entity Type:Individual
Prefix:MRS
First Name:DOLORES
Middle Name:CANCINO
Last Name:CLEMONS
Suffix:
Gender:F
Credentials:LCSW-BACS-MVF-CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 982
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-0118
Mailing Address - Country:US
Mailing Address - Phone:307-240-7380
Mailing Address - Fax:
Practice Address - Street 1:52 LAST CHANCE DRIVE
Practice Address - Street 2:BOX 982
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-9718
Practice Address - Country:US
Practice Address - Phone:307-240-7380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA61681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical