Provider Demographics
NPI:1801402094
Name:CLEMENS, KATY (LD)
Entity Type:Individual
Prefix:
First Name:KATY
Middle Name:
Last Name:CLEMENS
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 E HAWTHORN PKWY STE 235
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1454
Mailing Address - Country:US
Mailing Address - Phone:847-868-3435
Mailing Address - Fax:847-859-5885
Practice Address - Street 1:4100 SPRING VALLEY RD STE 515
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-3629
Practice Address - Country:US
Practice Address - Phone:817-751-7802
Practice Address - Fax:847-859-5885
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT86579133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered