Provider Demographics
NPI:1457910515
Name:CLEMENT, TRDIANN J
Entity Type:Individual
Prefix:
First Name:TRDIANN
Middle Name:J
Last Name:CLEMENT
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 1:288 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-2334
Mailing Address - Country:US
Mailing Address - Phone:973-855-9071
Mailing Address - Fax:
Practice Address - Street 1:288 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2334
Practice Address - Country:US
Practice Address - Phone:973-855-9071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health