Provider Demographics
NPI:1336778497
Name:CLEMENT, KERVINS (LCMHCAS)
Entity Type:Individual
Prefix:
First Name:KERVINS
Middle Name:
Last Name:CLEMENT
Suffix:
Gender:M
Credentials:LCMHCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1547 NEW GARDEN RD APT 2H
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-1550
Mailing Address - Country:US
Mailing Address - Phone:239-324-2837
Mailing Address - Fax:
Practice Address - Street 1:6614 SHALLOWFORD RD STE 250
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27023-9305
Practice Address - Country:US
Practice Address - Phone:336-945-0137
Practice Address - Fax:336-946-9084
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15687101YM0800X
NC26212101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health