Provider Demographics
NPI:1821581240
Name:CLEMMONS, BREYON
Entity Type:Individual
Prefix:
First Name:BREYON
Middle Name:
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 1:32770 OLD WOMEN SPRING RD.
Mailing Address - Street 2:
Mailing Address - City:LUCERNE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92356
Mailing Address - Country:US
Mailing Address - Phone:760-248-6612
Mailing Address - Fax:
Practice Address - Street 1:10755 APPLE VALLEY RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-3684
Practice Address - Country:US
Practice Address - Phone:562-440-1154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105719106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist