MEDICARE: DR. ANNE RUNDLE CLEMMER PSYD

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	103T00000X	Psychologist	373	MT
2	103T00000X	Psychologist	3134	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0000052611	OTHER	MT	BLUE CROSS SHIELD OF MONT

General Provider Information

NPI Number	:	1487675021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANNE RUNDLE CLEMMER PSYD

Provider Business Mailing Address
First Line	:	5858 CUMBRE VISTA WAY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80924-6000
Country	:	US
Telephone Number	:	719-649-8747
Fax Number	:

Provider Business Practice Location Address
First Line	:	5858 CUMBRE VISTA WAY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80924-6000
Country	:	US
Telephone Number	:	719-649-8747
Fax Number	:

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

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	11/01/2007

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