Provider Demographics
NPI:1467743930
Name:TAYLOR CLEMMONS, KRISTINA NICHOLE (LCMHC, LCAS)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:NICHOLE
Last Name:TAYLOR CLEMMONS
Suffix:
Gender:F
Credentials:LCMHC, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-6431
Mailing Address - Country:US
Mailing Address - Phone:910-343-0145
Mailing Address - Fax:
Practice Address - Street 1:120 COASTAL HORIZONS DR
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-6094
Practice Address - Country:US
Practice Address - Phone:910-754-4515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-02
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3394101YA0400X
NCA8665101YM0800X
NC8665101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health