Provider Demographics
NPI:1487751863
Name:CLEVENGER, RICHARD L
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:CLEVENGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PHILADELPHIA VETERANS AFFAIRS MEDICAL CENTER
Mailing Address - Street 2:3900 WOODLAND AVENUE
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-823-5800
Mailing Address - Fax:
Practice Address - Street 1:PHILADELPHIA VETERANS AFFAIRS MEDICAL CENTER
Practice Address - Street 2:3900 WOODLAND AVENUE
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-823-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLI200311104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker