Provider Demographics
NPI:1770640864
Name:CLEMENS, CYNTHIA ANN (OT)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:ANN
Last Name:CLEMENS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13117 SUNRIDGE WAY E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-4845
Mailing Address - Country:US
Mailing Address - Phone:253-905-7635
Mailing Address - Fax:
Practice Address - Street 1:13117 SUNRIDGE WAY E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-4845
Practice Address - Country:US
Practice Address - Phone:253-905-7635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00001124174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7682511Medicaid
WA4697CLOtherREGENCE BLUE SHIELD