Provider Demographics
NPI:1972288629
Name:CLEMENT, MARC WELDON
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:WELDON
Last Name:CLEMENT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19320 E ADMIRAL PL
Mailing Address - Street 2:
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015-3239
Mailing Address - Country:US
Mailing Address - Phone:918-340-5503
Mailing Address - Fax:
Practice Address - Street 1:19320 E ADMIRAL PL
Practice Address - Street 2:
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015-3239
Practice Address - Country:US
Practice Address - Phone:918-340-5503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health