Healthcare Provider Details

I. General information

NPI: 1033127188
Provider Name (Legal Business Name): M L CLEMSON CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 03/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 MASSACHUSETTS AVE
NORFOLK VA
23508-2118
US

IV. Provider business mailing address

602 MASSACHUSETTS AVE
NORFOLK VA
23508-2118
US

V. Phone/Fax

Practice location:
  • Phone: 757-622-6673
  • Fax: 757-622-1086
Mailing address:
  • Phone: 757-622-6673
  • Fax: 757-622-1086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number0015000529
License Number StateVA

VIII. Authorized Official

Name: MRS. MARY LOUISE CLEMSON
Title or Position: PRESIDENT
Credential: PSY CNS
Phone: 757-622-6673