Provider Demographics
NPI:1659818060
Name:KATHLYN CLEMENTELLI
Entity Type:Organization
Organization Name:KATHLYN CLEMENTELLI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:KATHLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMENTELLI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:408-204-8518
Mailing Address - Street 1:3212 TENLEY DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-3639
Mailing Address - Country:US
Mailing Address - Phone:408-204-8518
Mailing Address - Fax:
Practice Address - Street 1:3212 TENLEY DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95148-3639
Practice Address - Country:US
Practice Address - Phone:408-204-8518
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY28217103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA97726OtherUNITED HEALTHCARE