Provider Demographics
NPI:1336857705
Name:CLEMMER, MADYLIN S
Entity Type:Individual
Prefix:
First Name:MADYLIN
Middle Name:S
Last Name:CLEMMER
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 1:1200 E DIVISION ST APT 310
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56304-0934
Mailing Address - Country:US
Mailing Address - Phone:952-767-7222
Mailing Address - Fax:
Practice Address - Street 1:6701 PARKWAY CIR STE 300
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2849
Practice Address - Country:US
Practice Address - Phone:952-767-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician