Provider Demographics
NPI:1467575936
Name:CLEMSON BEHAVIORAL HEALTH PA
Entity Type:Organization
Organization Name:CLEMSON BEHAVIORAL HEALTH PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:D
Authorized Official - Last Name:MOUZON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-653-4112
Mailing Address - Street 1:398 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631-1432
Mailing Address - Country:US
Mailing Address - Phone:864-653-4112
Mailing Address - Fax:
Practice Address - Street 1:398 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-1432
Practice Address - Country:US
Practice Address - Phone:864-653-4112
Practice Address - Fax:864-653-4129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3804Medicaid
SCH97443Medicare UPIN