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General NPI Number Information
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NPI Number | 1033127188
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Entity Type | Organization
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Legal Business Name | M L CLEMSON CORPORATION
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Dates
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Enumeration Date | 08/04/2006
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Last Update Date | 03/26/2008
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Provider Practice Location Address
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Address Line | 602 MASSACHUSETTS AVE
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City | NORFOLK
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State | VA
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Zip | 23508-2118
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Country | US
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Telephone | 757-622-6673
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Fax | 757-622-1086
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Provider Business Mailing Address
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Address Line | 602 MASSACHUSETTS AVE
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City | NORFOLK
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State | VA
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Zip | 23508-2118
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Country | US
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Telephone | 757-622-6673
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Fax | 757-622-1086
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. MARY LOUISE CLEMSON
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Credential | PSY CNS
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Telephone | 757-622-6673
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WP0809X
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Taxonomy Name | Adult Psychiatric/Mental Health Registered Nurse
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License Number | 0015000529
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License Number State | VA
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