Provider Demographics
NPI:1518381193
Name:CLEMONS, ADRIAN R (LMT)
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:R
Last Name:CLEMONS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5645 W FISHER FWY
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48209-3144
Mailing Address - Country:US
Mailing Address - Phone:313-982-7165
Mailing Address - Fax:
Practice Address - Street 1:5645 W FISHER FWY
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48209-3144
Practice Address - Country:US
Practice Address - Phone:313-982-7165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501000219225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist