Provider Demographics
NPI:1831739929
Name:CLEMENTE, GINA NICOLE (MASTERS OF SCIENCE)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:NICOLE
Last Name:CLEMENTE
Suffix:
Gender:F
Credentials:MASTERS OF SCIENCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3084 N WOODS ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92865-1230
Mailing Address - Country:US
Mailing Address - Phone:714-876-4833
Mailing Address - Fax:
Practice Address - Street 1:550 N GOLDEN CIRCLE DR
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3959
Practice Address - Country:US
Practice Address - Phone:800-778-1772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA113691106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist