Healthcare Provider Details

I. General information

NPI: 1609852037
Provider Name (Legal Business Name): CLAYTON DAVID WILSON III LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 ZEMKE AVE
TAMPA FL
33621-5023
US

IV. Provider business mailing address

3250 ZEMKE AVE
TAMPA FL
33621-5023
US

V. Phone/Fax

Practice location:
  • Phone: 813-420-3988
  • Fax:
Mailing address:
  • Phone: 813-420-3988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number069614-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: