Provider Demographics
NPI:1295323657
Name:CLEMONS, GEORQUETTA M
Entity type:Individual
Prefix:
First Name:GEORQUETTA
Middle Name:M
Last Name:CLEMONS
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 1:9104 SHIPHERD CT
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-1041
Mailing Address - Country:US
Mailing Address - Phone:216-820-8343
Mailing Address - Fax:
Practice Address - Street 1:9104 SHIPHERD CT
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1041
Practice Address - Country:US
Practice Address - Phone:216-820-8343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-01
Last Update Date:2021-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.022698225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty