Provider Demographics
NPI:1588666549
Name:CLEMENS, MARNIE (DPT)
Entity Type:Individual
Prefix:
First Name:MARNIE
Middle Name:
Last Name:CLEMENS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 ORCHARD AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1736
Mailing Address - Country:US
Mailing Address - Phone:304-842-6008
Mailing Address - Fax:
Practice Address - Street 1:306 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1751
Practice Address - Country:US
Practice Address - Phone:304-842-3137
Practice Address - Fax:304-842-3138
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-02
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001091174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV01071873100OtherWORKERS' COMPENSATION
WV010718731002OtherBC/BS
WV0157976001Medicaid
WV650023876OtherRAILRAOD MEDICARE
WV7508068OtherAETNA
WV398791OtherOPTIMUM CHOICE
WV79582OtherHEALTH ASSURANCE
WVWV51916BOtherHEALTH PLAN
WV1382862OtherUMWA
WV7508068OtherAETNA