Provider Demographics
NPI:1831605765
Name:CLEMONS, SHANEQUIA DESHAWN
Entity type:Individual
Prefix:DR
First Name:SHANEQUIA
Middle Name:DESHAWN
Last Name:CLEMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:SHANEQUIA
Other - Middle Name:NICKI
Other - Last Name:CLEMONS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2180 REESE ST
Mailing Address - Street 2:
Mailing Address - City:LACKLAND AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78236-1042
Mailing Address - Country:US
Mailing Address - Phone:210-606-2319
Mailing Address - Fax:
Practice Address - Street 1:2180 REESE ST
Practice Address - Street 2:
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236-1042
Practice Address - Country:US
Practice Address - Phone:305-912-3482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-14
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103K00000X, 175T00000X, 374K00000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No175T00000XOther Service ProvidersPeer Specialist
No374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner