=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407743107
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT CLEMMONS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2025
-----------------------------------------------------
Last Update Date | 06/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 COURT ST
-----------------------------------------------------
City | MADISONVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42431-2502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-824-9355
-----------------------------------------------------
Fax | 270-824-8212
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 568 BAILEY DR
-----------------------------------------------------
City | MADISONVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42431-1328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-339-9647
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------