Provider Demographics
NPI:1639344419
Name:CLIME, MARY LOU
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOU
Last Name:CLIME
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 1:704 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-7438
Mailing Address - Country:US
Mailing Address - Phone:386-409-3486
Mailing Address - Fax:
Practice Address - Street 1:704 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7438
Practice Address - Country:US
Practice Address - Phone:386-409-3486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL230395700Medicaid