Provider Demographics
NPI:1740779784
Name:WILWERT, CLEMENTINE LEON (RBT)
Entity Type:Individual
Prefix:
First Name:CLEMENTINE
Middle Name:LEON
Last Name:WILWERT
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4557 STANDING BLUFF WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-5379
Mailing Address - Country:US
Mailing Address - Phone:702-743-4254
Mailing Address - Fax:
Practice Address - Street 1:2715 E RUSSELL RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-2426
Practice Address - Country:US
Practice Address - Phone:702-848-1696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-04
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician