Healthcare Provider Details

I. General information

NPI: 1437351749
Provider Name (Legal Business Name): MR. DWYANE JOSEPH CLEMENTS I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12440 IMPERIAL HWY STE 770
NORWALK CA
90650-3177
US

IV. Provider business mailing address

12440 IMPERIAL HWY STE 770
NORWALK CA
90650-3177
US

V. Phone/Fax

Practice location:
  • Phone: 562-402-0688
  • Fax: 562-402-3032
Mailing address:
  • Phone: 213-220-1915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCICA02131119
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: