Provider Demographics
NPI:1659924298
Name:CLEMENTS, MICHELLE ANGELA (CASAC)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ANGELA
Last Name:CLEMENTS
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:MASTIC
Mailing Address - State:NY
Mailing Address - Zip Code:11950-2917
Mailing Address - Country:US
Mailing Address - Phone:631-772-3217
Mailing Address - Fax:631-874-3786
Practice Address - Street 1:1235 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:MASTIC
Practice Address - State:NY
Practice Address - Zip Code:11950-2917
Practice Address - Country:US
Practice Address - Phone:631-772-3217
Practice Address - Fax:631-874-3786
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY26410101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)