Provider Demographics
NPI:1376903294
Name:CLUMECK, MARY ANNETTA (MS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNETTA
Last Name:CLUMECK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 THE CITY DR S
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3201
Mailing Address - Country:US
Mailing Address - Phone:714-456-6682
Mailing Address - Fax:714-456-5725
Practice Address - Street 1:101 THE CITY DR S
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-456-6682
Practice Address - Fax:714-456-5725
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8632235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist