MEDICARE: LAURA A CLEVENGER LMFT

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	106H00000X	Marriage & Family Therapist	MT 2792	FL

General Provider Information

NPI Number	:	1871930859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA A CLEVENGER LMFT

Provider Business Mailing Address
First Line	:	2286 WEDNESDAY ST STE 1
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-8310
Country	:	US
Telephone Number	:	850-567-1102
Fax Number	:	850-298-8857

Provider Business Practice Location Address
First Line	:	2286 WEDNESDAY ST STE 1
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-8310
Country	:	US
Telephone Number	:	850-567-1102
Fax Number	:	850-298-8857

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

Provider Enumeration Date	:	05/30/2013
Last Update Date	:	05/30/2013

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