Provider Demographics
NPI:1194870881
Name:CLEMENTS, GEORGE WHITNEY (MSW)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:WHITNEY
Last Name:CLEMENTS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N. BROAD ST.
Mailing Address - Street 2:MANKATO MENTAL HEALTH ASSOCIATES
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001
Mailing Address - Country:US
Mailing Address - Phone:507-345-4448
Mailing Address - Fax:507-345-6761
Practice Address - Street 1:201 N. BROAD ST.
Practice Address - Street 2:MANKATO MENTAL HEALTH ASSOCIATES
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001
Practice Address - Country:US
Practice Address - Phone:507-345-4448
Practice Address - Fax:507-345-6761
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17134101YM0800X
MNLICSW171341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN722391045623OtherPREFERRED ONE
MN138108OtherUCARE
MN81G42CLOtherBLUE CROSS
MNHP58819OtherHEALTH PARTNERS
MN061625700Medicaid
MN061625700Medicaid