MEDICARE: DR. CAROL HART CLEMENKO PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY8757	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PSY8757	OTHER	CA	LICENSE

General Provider Information

NPI Number	:	1316977853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAROL HART CLEMENKO PH.D.

Provider Business Mailing Address
First Line	:	4096 PARK BLVD.
Second Line	:	SUITE C
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-2620
Country	:	US
Telephone Number	:	619-260-0865
Fax Number	:	619-260-0640

Provider Business Practice Location Address
First Line	:	4096 PARK BLVD.
Second Line	:	SUITE C
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-2620
Country	:	US
Telephone Number	:	619-260-0865
Fax Number	:	619-260-0640

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	07/08/2007

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