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General NPI Number Information
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NPI Number | 1992711154
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Entity Type | Individual
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Provider Name | DEBORAH JEAN CLEMMENSEN M.EQ.
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Gender | Female
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Dates
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Enumeration Date | 07/31/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 10520 WAYZATA BLVD WOODSIDE OFFICE PARK
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City | MINNETONKA
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State | MN
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Zip | 55305-1511
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Country | US
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Telephone | 952-767-0190
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Fax | 952-544-3401
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Provider Business Mailing Address
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Address Line | 3525 IRVING AVE S
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City | MINNEAPOLIS
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State | MN
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Zip | 55408-3325
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Country | US
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Telephone | 612-827-0759
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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 | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | LP2635
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License Number State | MN
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