Provider Demographics
NPI:1841037140
Name:CLEMENS, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CLEMENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:JO
Other - Last Name:CLEMENS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCMHCA
Mailing Address - Street 1:6223 GOOD NEWS CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:STANTONSBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27883-9796
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1319 N BRIGHTLEAF BLVD STE F
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-4876
Practice Address - Country:US
Practice Address - Phone:919-934-1312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18848101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health