Provider Demographics
NPI:1609589092
Name:CLEMENT, KELLIE L
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:L
Last Name:CLEMENT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 POPLAR ST # 2
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307-3231
Mailing Address - Country:US
Mailing Address - Phone:973-680-2360
Mailing Address - Fax:
Practice Address - Street 1:139 POPLAR ST # 2
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07307-3231
Practice Address - Country:US
Practice Address - Phone:973-680-2360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-30
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst