=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528608361
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HARRY TYRELL CLAYTON LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2020
-----------------------------------------------------
Last Update Date | 03/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7107 KOUFAX CT
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23234-8217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-243-9150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9520 IRON BRIDGE RD STE 31
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23832-6455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-243-9150
-----------------------------------------------------
Fax | 804-715-4358
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0904011438
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------