Provider Demographics
NPI:1255625125
Name:CLEM, CLYDE LEE IV (PT)
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:LEE
Last Name:CLEM
Suffix:IV
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3934 HILLSMAN LN
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-8724
Mailing Address - Country:US
Mailing Address - Phone:770-733-9707
Mailing Address - Fax:
Practice Address - Street 1:3934 HILLSMAN LN
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-8724
Practice Address - Country:US
Practice Address - Phone:770-733-9707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010069225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist