Basic Information
| Provider Information | |||||||||
| NPI: | 1821581240 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLEMMONS | ||||||||
| FirstName: | BREYON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32770 OLD WOMEN SPRING RD. | ||||||||
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| City: | LUCERNE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602486612 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10755 APPLE VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923083684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624401154 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2018 | ||||||||
| LastUpdateDate: | 08/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 105719 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.