Basic Information
| Provider Information | |||||||||
| NPI: | 1306250436 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEMONS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JENNIFER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT, ATC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHELUS | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | JENNIFER | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT, ATC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 33900 HARPER AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480354258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864169100 | ||||||||
| FaxNumber: | 5864169103 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 N 2ND ST | ||||||||
| Address2: | |||||||||
| City: | ST CHARLES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601741869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305264200 | ||||||||
| FaxNumber: | 6305264201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2014 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT011457 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.