Provider Demographics
NPI:1942912266
Name:CLEMENTS, GRACE TAIYU EVADARE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:TAIYU EVADARE
Last Name:CLEMENTS
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 1:510 NORTHGATE PARK DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3486
Mailing Address - Country:US
Mailing Address - Phone:888-446-7301
Mailing Address - Fax:
Practice Address - Street 1:510 NORTHGATE PARK DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3486
Practice Address - Country:US
Practice Address - Phone:888-446-7301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0Medicaid