Provider Demographics
NPI:1346924354
Name:CLEMENTS, COLLEEN (LAC, CH)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:CLEMENTS
Suffix:
Gender:F
Credentials:LAC, CH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 N SHORE RD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-5347
Mailing Address - Country:US
Mailing Address - Phone:443-802-9061
Mailing Address - Fax:
Practice Address - Street 1:367 N SHORE RD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-5347
Practice Address - Country:US
Practice Address - Phone:410-883-8104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02832171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist