Provider Demographics
NPI:1346662632
Name:EXILHOMME, CLIFFORD
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:
Last Name:EXILHOMME
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 1:12 POPE ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-2106
Mailing Address - Country:US
Mailing Address - Phone:978-397-9800
Mailing Address - Fax:
Practice Address - Street 1:12 POPE ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-2106
Practice Address - Country:US
Practice Address - Phone:978-397-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA042104791Medicaid