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1770986069 NPI number — KELLY CLEMENTS PSYD

NPI Number: 1770986069
Health Care Provider/Practitioner: KELLY CLEMENTS PSYD

Information about “1770986069” NPI (KELLY CLEMENTS PSYD) exists in 1770986069 in HTML format HTML  |  1770986069 in plain Text format TXT  |  1770986069 in PDF (Portable Document Format) PDF  |  1770986069 in an XML format XML  formats.

NPI Number : 1770986069 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1770986069",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "CLEMENTS",
    "FirstName": "KELLY",
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "PSYD",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": "VALDIVIA",
    "OtherFirstName": "KELLY",
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": "PSYD",
    "OtherLastNameTypeCode": "1",
    "FirstLineMailingAddress": "7974 UW HEALTH CT",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "MIDDLETON",
    "MailingAddressStateName": "WI",
    "MailingAddressPostalCode": "53562-5531",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": null,
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "3434 E WASHINGTON AVE",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "MADISON",
    "PracticeLocationAddressStateName": "WI",
    "PracticeLocationAddressPostalCode": "53704-4155",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "608-443-5480",
    "PracticeLocationAddressFaxNumber": "608-443-5554",
    "EnumerationDate": "10/01/2014",
    "LastUpdateDate": "01/05/2021",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "103T00000X",
        "TaxonomyName": "Psychologist",
        "LicenseNumber": null,
        "LicenseNumberStateCode": null,
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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