Provider Demographics
NPI:1841948866
Name:CLEMENT, JAMES W
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:CLEMENT
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 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5500 N COCOA BLVD
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32927-6006
Practice Address - Country:US
Practice Address - Phone:321-349-0343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-17
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21-156895106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109657200Medicaid