Provider Demographics
NPI:1588859672
Name:CLEMENTS, KENNA M (CACIII)
Entity Type:Individual
Prefix:
First Name:KENNA
Middle Name:M
Last Name:CLEMENTS
Suffix:
Gender:F
Credentials:CACIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81602-0040
Mailing Address - Country:US
Mailing Address - Phone:970-945-2241
Mailing Address - Fax:970-945-5523
Practice Address - Street 1:350 MCKINLEY STREET
Practice Address - Street 2:
Practice Address - City:WALDEN
Practice Address - State:CO
Practice Address - Zip Code:80480
Practice Address - Country:US
Practice Address - Phone:970-723-0055
Practice Address - Fax:970-723-4732
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6872101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)