Healthcare Provider Details

I. General information

NPI: 1396659017
Provider Name (Legal Business Name): CLARK GRAYSON GIVENS ED. S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

746 INDIAN TRL
MARTINSVILLE VA
24112-4520
US

IV. Provider business mailing address

714 INDIAN TRL
MARTINSVILLE VA
24112-4505
US

V. Phone/Fax

Practice location:
  • Phone: 276-403-5820
  • Fax:
Mailing address:
  • Phone: 276-732-2036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberPPS-0609715
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: