Provider Demographics
NPI:1609684737
Name:CLEM, LORA MARIE (LADC)
Entity type:Individual
Prefix:
First Name:LORA
Middle Name:MARIE
Last Name:CLEM
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3231 1ST AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-4407
Mailing Address - Country:US
Mailing Address - Phone:612-238-6553
Mailing Address - Fax:
Practice Address - Street 1:3231 1ST AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-4407
Practice Address - Country:US
Practice Address - Phone:612-238-6553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303496101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor