Provider Demographics
NPI:1841423332
Name:CLEMONS, MELANIE R (PHD)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:R
Last Name:CLEMONS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1051
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-6051
Mailing Address - Country:US
Mailing Address - Phone:510-982-6765
Mailing Address - Fax:
Practice Address - Street 1:470 27TH ST
Practice Address - Street 2:BAWAR
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2413
Practice Address - Country:US
Practice Address - Phone:510-982-6765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-31
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 24578103TF0000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent