Provider Demographics
NPI:1811193881
Name:CLEMMONS, AMELIA HOLLAND
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:HOLLAND
Last Name:CLEMMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3370 CLONINGER RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:NC
Mailing Address - Zip Code:28034-8528
Mailing Address - Country:US
Mailing Address - Phone:704-922-5979
Mailing Address - Fax:
Practice Address - Street 1:418 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:NC
Practice Address - Zip Code:28098-1806
Practice Address - Country:US
Practice Address - Phone:704-824-2381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4562101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool