Healthcare Provider Details

I. General information

NPI: 1366587040
Provider Name (Legal Business Name): CHARLES RUSSELL CLIFTON JR. PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 12/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 NW 40TH TERRACE SUITE B
GAINESVILLE FL
32605
US

IV. Provider business mailing address

2121 NW 40TH TER SUITE B
GAINESVILLE FL
32605-5813
US

V. Phone/Fax

Practice location:
  • Phone: 352-336-2888
  • Fax: 352-371-1730
Mailing address:
  • Phone: 352-336-2888
  • Fax: 352-371-1730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY2731
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: