Provider Demographics
NPI:1992711154
Name:CLEMMENSEN, DEBORAH JEAN (MEQ)
Entity type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:JEAN
Last Name:CLEMMENSEN
Suffix:
Gender:F
Credentials:MEQ
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 IRVING AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-3325
Mailing Address - Country:US
Mailing Address - Phone:612-827-0759
Mailing Address - Fax:
Practice Address - Street 1:10520 WAYZATA BLVD
Practice Address - Street 2:WOODSIDE OFFICE PARK
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1511
Practice Address - Country:US
Practice Address - Phone:952-767-0190
Practice Address - Fax:952-544-3401
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2635103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent