Provider Demographics
NPI:1720077670
Name:CLEMENTS, BRENDA SUE (DPT, MTC)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:SUE
Last Name:CLEMENTS
Suffix:
Gender:F
Credentials:DPT, MTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1827 HARRISON AVE
Mailing Address - Street 2:BUILDING 4
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-7605
Mailing Address - Country:US
Mailing Address - Phone:850-872-7022
Mailing Address - Fax:850-872-7021
Practice Address - Street 1:1827 HARRISON AVE
Practice Address - Street 2:BUILDING 4
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-7605
Practice Address - Country:US
Practice Address - Phone:850-872-7022
Practice Address - Fax:850-872-7021
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19943225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2288818OtherAETNA
FLY909JOtherBCBS PROVIDER NUMBER
FL2288818OtherAETNA