Provider Demographics
NPI:1518570464
Name:CLEMONS, MYA (LSW)
Entity Type:Individual
Prefix:
First Name:MYA
Middle Name:
Last Name:CLEMONS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 GRAHAM RD STE 101
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44221-1051
Mailing Address - Country:US
Mailing Address - Phone:330-603-3980
Mailing Address - Fax:
Practice Address - Street 1:401 TUSCARAWAS ST W STE 501
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44702-2045
Practice Address - Country:US
Practice Address - Phone:440-260-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X, 172V00000X
OHS2106202104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker