Susan D Clemons, PHD. – Clinical Psychologist

Key facts

NPI: 1255464855
Entity type: Individual (NPI type 1)
Primary specialty: Clinical Psychologist 103TC0700X
License: 06-22P (AR)
Practice address: 2013 N Green Acres Rd
Suite C
Fayetteville, AR 72703
Phone: (479) 444-3354
Fax: (479) 555-6770
NPI assigned: Mar 13, 2007
Sex: Female
Sole proprietor: Yes

Medicare participation

Medicare fee-for-service enrollment: Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD): No
Credentials: Doctor of Philosophy

State licenses

License	State	Type	Specialty
06-22P	AR	MD	Clinical Psychologist

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Clinical Psychologist	103TC0700X	06-22P	AR	Yes

Addresses

Primary practice location

2013 N Green Acres Rd
Suite C
Fayetteville, AR 72703

Mailing address

2013 N Green Acres Rd
Suite C
Fayetteville, AR 72703
Phone (479) 444-3354

Other identifiers

Identifier	Type	State	Issuer
20-5113370	Other	IL	TAX IDENTIFICATION NUMBER

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Apr 28, 2020.

{
    "created_epoch": "1173744000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1588032000000",
    "number": "1255464855",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2013 N GREEN ACRES RD",
            "address_2": "SUITE C",
            "city": "FAYETTEVILLE",
            "state": "AR",
            "postal_code": "72703",
            "telephone_number": "479-444-3354",
            "fax_number": "479-555-6770"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2013 N GREEN ACRES RD",
            "address_2": "SUITE C",
            "city": "FAYETTEVILLE",
            "state": "AR",
            "postal_code": "72703",
            "telephone_number": "479-444-3354",
            "fax_number": "479-555-6770"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLEMONS",
        "first_name": "SUSAN",
        "middle_name": "D",
        "credential": "PHD.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2007-03-13",
        "last_updated": "2020-04-28",
        "certification_date": "2020-04-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "AR",
            "license": "06-22P",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TAX IDENTIFICATION NUMBER",
            "identifier": "20-5113370",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fayetteville, AR

All providers in Fayetteville, AR · Clinical Psychologist in Arkansas

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 28, 2020. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.