Provider Demographics
NPI:1023796414
Name:CLEMENTS, KRISTIN SCOTT
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:SCOTT
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 1:3961 COUNTY ROAD 557A
Mailing Address - Street 2:
Mailing Address - City:POLK CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33868-9210
Mailing Address - Country:US
Mailing Address - Phone:863-797-6999
Mailing Address - Fax:
Practice Address - Street 1:454 W PIPKIN RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2545
Practice Address - Country:US
Practice Address - Phone:813-548-7259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23-281595103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst