Provider Demographics
NPI:1053719971
Name:CLEM, CHRISTIE (ATC/LAT)
Entity type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:
Last Name:CLEM
Suffix:
Gender:F
Credentials:ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 PURDUE ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-5350
Mailing Address - Country:US
Mailing Address - Phone:919-841-2362
Mailing Address - Fax:
Practice Address - Street 1:800 PURDUE ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-5350
Practice Address - Country:US
Practice Address - Phone:919-841-2362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-09
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP16568225100000X
NC15792255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer