Provider Demographics
NPI:1962990903
Name:CLEMONS, LARRY ALEXANDER (CDCA)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:ALEXANDER
Last Name:CLEMONS
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5217 WINSOME WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-2692
Mailing Address - Country:US
Mailing Address - Phone:419-571-0011
Mailing Address - Fax:
Practice Address - Street 1:2775 STATE ROUTE 39
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-9466
Practice Address - Country:US
Practice Address - Phone:419-747-3322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH000844101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty