Provider Demographics
NPI:1700630167
Name:CLEMENTS, IREONNA BAJA
Entity Type:Individual
Prefix:
First Name:IREONNA
Middle Name:BAJA
Last Name:CLEMENTS
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 1:3614 BLESSING ST APT 306
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-4885
Mailing Address - Country:US
Mailing Address - Phone:843-372-3534
Mailing Address - Fax:
Practice Address - Street 1:8535 CLIFF CAMERON DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-5909
Practice Address - Country:US
Practice Address - Phone:704-717-7477
Practice Address - Fax:704-717-7457
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0202771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty