Provider Demographics
NPI:1871686501
Name:CLEMONS, MARK A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:CLEMONS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 RICHARDSON ST.
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-3430
Mailing Address - Country:US
Mailing Address - Phone:903-677-4800
Mailing Address - Fax:903-677-4803
Practice Address - Street 1:506 RICHARDSON ST.
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-3430
Practice Address - Country:US
Practice Address - Phone:903-677-4800
Practice Address - Fax:903-677-4803
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32132103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165882501Medicaid
TX610720Medicare PIN