Provider Demographics
NPI:1316977853
Name:CLEMENKO, CAROL HART (PHD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:HART
Last Name:CLEMENKO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4096 PARK BLVD.
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2620
Mailing Address - Country:US
Mailing Address - Phone:619-260-0865
Mailing Address - Fax:619-260-0640
Practice Address - Street 1:4096 PARK BLVD.
Practice Address - Street 2:SUITE C
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2620
Practice Address - Country:US
Practice Address - Phone:619-260-0865
Practice Address - Fax:619-260-0640
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8757103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY8757OtherLICENSE
CAPSY8757OtherLICENSE