Basic Information
| Provider Information | |||||||||
| NPI: | 1497040828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRAZY THUNDER | ||||||||
| FirstName: | CLEMENT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | CADC II | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 541 S HAM LN STE A&B | ||||||||
| Address2: | |||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952423530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092248940 | ||||||||
| FaxNumber: | 2092245076 | ||||||||
| Practice Location | |||||||||
| Address1: | 541 S HAM LN STE A&B | ||||||||
| Address2: | |||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952423530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092248940 | ||||||||
| FaxNumber: | 2092245076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2011 | ||||||||
| LastUpdateDate: | 03/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 862 | NE | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.