Healthcare Provider Details

I. General information

NPI: 1639380819
Provider Name (Legal Business Name): CLINTON LEVOY HUFFMAN III MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 MONO WAY
SONORA CA
95370-5163
US

IV. Provider business mailing address

17401 SMOKEY RIVER DR
SONORA CA
95370-8925
US

V. Phone/Fax

Practice location:
  • Phone: 209-533-3553
  • Fax:
Mailing address:
  • Phone: 209-586-3898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC38520
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: