Provider Demographics
NPI:1659463768
Name:CLEMENT, LISA ANNE (LICSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:CLEMENT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1307
Mailing Address - Country:US
Mailing Address - Phone:515-244-2267
Mailing Address - Fax:515-244-1922
Practice Address - Street 1:808 5TH AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1307
Practice Address - Country:US
Practice Address - Phone:515-244-2267
Practice Address - Fax:515-244-1922
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN142011041C0700X
IA0076391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN445297600Medicaid