Healthcare Provider Details

I. General information

NPI: 1275737314
Provider Name (Legal Business Name): CLAYTON PUBLIC SCHOOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 PINE STREET
CLAYTON OK
74536-0190
US

IV. Provider business mailing address

100 PINE STREET
CLAYTON OK
74536-0190
US

V. Phone/Fax

Practice location:
  • Phone: 918-569-4492
  • Fax: 918-569-7757
Mailing address:
  • Phone: 918-569-4492
  • Fax: 918-569-7757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3157
License Number StateOK

VIII. Authorized Official

Name: MRS. PATRICIA LEE GLENN
Title or Position: ELEMENTARY PRINCIPAL
Credential:
Phone: 918-569-4158