Provider Demographics
NPI:1376249896
Name:CLEMENTS, CHRISTINA MARIE (M ED, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:MARIE
Last Name:CLEMENTS
Suffix:
Gender:F
Credentials:M ED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51910 WILLIS ST
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-8073
Mailing Address - Country:US
Mailing Address - Phone:615-796-8559
Mailing Address - Fax:
Practice Address - Street 1:51910 WILLIS ST
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-8073
Practice Address - Country:US
Practice Address - Phone:615-796-8559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7401001898103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst