MEDICARE: MR. CHARLES FREDERICK CLEMONS SR. L.P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	17321	TX

General Provider Information

NPI Number	:	1770612723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES FREDERICK CLEMONS SR. L.P.C.

Provider Business Mailing Address
First Line	:	10806 EAST HIGHWAY 29
Second Line	:
City	:	GEORGETOWN
State	:	TX
Zip	:	78626-2403
Country	:	US
Telephone Number	:	512-217-9287
Fax Number	:	512-233-6363

Provider Business Practice Location Address
First Line	:	1907 N LAMAR BLVD STE 354
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78705-4900
Country	:	US
Telephone Number	:	512-217-9287
Fax Number	:	512-233-6363

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	07/08/2007

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