Healthcare Provider Details

I. General information

NPI: 1275159352
Provider Name (Legal Business Name): MR. DARRELL ST. CLEMMONS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2020
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ROUTE 108
SOMERSWORTH NH
03878-1119
US

IV. Provider business mailing address

36 CANAL ST APT 407
SOMERSWORTH NH
03878-3262
US

V. Phone/Fax

Practice location:
  • Phone: 603-953-0077
  • Fax: 603-953-0078
Mailing address:
  • Phone: 401-396-7580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: