Healthcare Provider Details

I. General information

NPI: 1912459868
Provider Name (Legal Business Name): WADLEY CLAUTHER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2857 LINDEN BLVD
BROOKLYN NY
11208-5126
US

IV. Provider business mailing address

12155 GRAYSON ST
SPRINGFIELD GARDENS NY
11413-1039
US

V. Phone/Fax

Practice location:
  • Phone: 718-235-3100
  • Fax:
Mailing address:
  • Phone: 917-371-7440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: