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General NPI Number Information
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NPI Number | 1346004850
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Entity Type | Individual
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Provider Name | JOHN B CLAYTON ICADC
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Gender | Male
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Dates
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Enumeration Date | 02/06/2024
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Last Update Date | 02/06/2024
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Provider Practice Location Address
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Address Line | 1275 N 400 E
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City | RUPERT
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State | ID
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Zip | 83350-8538
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Country | US
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Telephone | 208-271-4363
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Fax |
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Provider Business Mailing Address
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Address Line | 2267 RIDGE AVE
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City | CLERMONT
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State | FL
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Zip | 34711-8532
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Country | US
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Telephone | 407-668-7834
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 0702989
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License Number State | FL
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