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General NPI Number Information
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NPI Number | 1043006711
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Entity Type | Individual
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Provider Name | CLINT LEVIS NGASSEM
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Gender | Male
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Dates
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Enumeration Date | 04/17/2025
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Last Update Date | 04/17/2025
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Provider Practice Location Address
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Address Line | 11162 PALM TERRACE LN
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City | RIVERSIDE
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State | CA
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Zip | 92505-2338
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Country | US
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Telephone | 951-687-7330
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Fax |
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Provider Business Mailing Address
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Address Line | 1699 E WASHINGTON ST APT 2174
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City | COLTON
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State | CA
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Zip | 92324-4699
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Country | US
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Telephone | 909-780-5399
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 95034752
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License Number State | CA
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