Provider Demographics
NPI:1821595448
Name:CLEMENTI, ANTHONY THOMAS
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:THOMAS
Last Name:CLEMENTI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:784 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-5243
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1350 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-2422
Practice Address - Country:US
Practice Address - Phone:805-474-2154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CAMPSS-UGENLR175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker