Provider Demographics
NPI:1689941965
Name:CLEMONS, MARK JAMES (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:JAMES
Last Name:CLEMONS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-1410
Mailing Address - Country:US
Mailing Address - Phone:518-453-6710
Mailing Address - Fax:518-453-6733
Practice Address - Street 1:30 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-1410
Practice Address - Country:US
Practice Address - Phone:518-453-6710
Practice Address - Fax:518-453-6733
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY730711141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical