Provider Demographics
NPI:1366288334
Name:CLEMENTE, MARY GAIL Y (CAMTC)
Entity type:Individual
Prefix:
First Name:MARY GAIL
Middle Name:Y
Last Name:CLEMENTE
Suffix:
Gender:F
Credentials:CAMTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:753 WALKER AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-2736
Mailing Address - Country:US
Mailing Address - Phone:408-548-0576
Mailing Address - Fax:
Practice Address - Street 1:1211 EMBARCADERO STE D
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606-5117
Practice Address - Country:US
Practice Address - Phone:408-548-0576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2219225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist