Healthcare Provider Details

I. General information

NPI: 1205992146
Provider Name (Legal Business Name): ROBERT L CLEMONS II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 04/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 DEVANT ST SUITE 702
FAYETTEVILLE GA
30214-2710
US

IV. Provider business mailing address

101 DEVANT ST SUITE 702
FAYETTEVILLE GA
30214-2710
US

V. Phone/Fax

Practice location:
  • Phone: 770-460-0970
  • Fax: 866-758-5731
Mailing address:
  • Phone: 770-460-0970
  • Fax: 866-758-5731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number004041
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateGA

VIII. Authorized Official

Name: MR. ROBERT L CLEMONS II
Title or Position: CEO-CLINICAL DIRECTOR
Credential: LPC
Phone: 770-460-0970