Provider Demographics
NPI:1790660629
Name:CLEMONS, HEATHER MARIE
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:CLEMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 S STATE ROAD 23
Mailing Address - Street 2:
Mailing Address - City:KNOX
Mailing Address - State:IN
Mailing Address - Zip Code:46534-8233
Mailing Address - Country:US
Mailing Address - Phone:574-806-2727
Mailing Address - Fax:
Practice Address - Street 1:2855 MILLER DR STE 109
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-8091
Practice Address - Country:US
Practice Address - Phone:317-669-1232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-08
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician