Provider Demographics
NPI:1043006711
Name:NGASSEM, CLINT LEVIS
Entity type:Individual
Prefix:
First Name:CLINT
Middle Name:LEVIS
Last Name:NGASSEM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1699 E WASHINGTON ST APT 2174
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-4699
Mailing Address - Country:US
Mailing Address - Phone:909-780-5399
Mailing Address - Fax:
Practice Address - Street 1:11162 PALM TERRACE LN
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-2338
Practice Address - Country:US
Practice Address - Phone:951-687-7330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-17
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95034752363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health