Provider Demographics
NPI:1245465335
Name:CLEMENTI, MARK A (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:CLEMENTI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 OLD COURTHOUSE SQ STE 400
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4924
Mailing Address - Country:US
Mailing Address - Phone:707-527-0456
Mailing Address - Fax:707-527-1013
Practice Address - Street 1:50 OLD COURTHOUSE SQ STE 400
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4924
Practice Address - Country:US
Practice Address - Phone:707-527-0456
Practice Address - Fax:707-527-1013
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 13898103T00000X, 103TB0200X, 103TC0700X, 103TE1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports