=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871686501
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK A CLEMONS PSY.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2006
-----------------------------------------------------
Last Update Date | 07/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 506 RICHARDSON ST.
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75751-3430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-677-4800
-----------------------------------------------------
Fax | 903-677-4803
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 506 RICHARDSON ST.
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75751-3430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-677-4800
-----------------------------------------------------
Fax | 903-677-4803
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 32132
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------