Healthcare Provider Details

I. General information

NPI: 1578045167
Provider Name (Legal Business Name): COURTNEY CLEMMONS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2018
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 COLEMAN DR
ST AUGUSTINE FL
32084-2873
US

IV. Provider business mailing address

2 COLEMAN DR
ST AUGUSTINE FL
32084-2873
US

V. Phone/Fax

Practice location:
  • Phone: 727-967-1036
  • Fax:
Mailing address:
  • Phone: 727-967-1036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSZ8700
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: