Provider Demographics
NPI:1629492574
Name:CLEMENTS, BWANA M (MSW)
Entity Type:Individual
Prefix:MR
First Name:BWANA
Middle Name:M
Last Name:CLEMENTS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 E 44TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-1905
Mailing Address - Country:US
Mailing Address - Phone:317-600-6714
Mailing Address - Fax:
Practice Address - Street 1:717 E 44TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-1905
Practice Address - Country:US
Practice Address - Phone:317-600-6714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health