Provider Demographics
NPI:1609536713
Name:CLEMMONS, TAYLOR NICHOLAS
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:NICHOLAS
Last Name:CLEMMONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 1ST ST APT 203
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2672
Mailing Address - Country:US
Mailing Address - Phone:910-625-9474
Mailing Address - Fax:
Practice Address - Street 1:5821 W MAPLE RD STE 195
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-2275
Practice Address - Country:US
Practice Address - Phone:248-831-0293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician