Provider Demographics
NPI:1134184518
Name:CLEMMONS, BRIAN MARK (LPC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:MARK
Last Name:CLEMMONS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 MONTGOMERY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2600
Mailing Address - Country:US
Mailing Address - Phone:833-510-4357
Mailing Address - Fax:866-460-2997
Practice Address - Street 1:3704 OLD FOREST RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-6943
Practice Address - Country:US
Practice Address - Phone:833-510-4357
Practice Address - Fax:866-460-2997
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003128101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA105735OtherANTHEM
VA105735OtherHEALTHKEEPERS
VA004945115Medicaid
VA105735Medicaid
VAO83784OtherSOUTHERN HEALTH
VAO83784Medicaid