Provider Demographics
NPI:1538281936
Name:CLEMMONS, TINA MARIE (PTA)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:MARIE
Last Name:CLEMMONS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 S TENNESSEE AVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-2259
Mailing Address - Country:US
Mailing Address - Phone:304-262-2928
Mailing Address - Fax:
Practice Address - Street 1:302 S TENNESSEE AVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2259
Practice Address - Country:US
Practice Address - Phone:304-262-2928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000108225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant