Healthcare Provider Details

I. General information

NPI: 1316856016
Provider Name (Legal Business Name): CLEMENTINE HOLISTIC HEALING FOR WOMEN '
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17505 W CATAWBA AVE STE 130
CORNELIUS NC
28031-8058
US

IV. Provider business mailing address

17505 W CATAWBA AVE STE 130
CORNELIUS NC
28031-8058
US

V. Phone/Fax

Practice location:
  • Phone: 415-902-0366
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ROBIN D TALLENT
Title or Position: OWNER
Credential: PMHNP
Phone: 415-902-0366