=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609443647
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID CLAY PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2021
-----------------------------------------------------
Last Update Date | 06/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 435 N JACKSON ST
-----------------------------------------------------
City | QUINCY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32351-1731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-345-7989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 435 N JACKSON ST
-----------------------------------------------------
City | QUINCY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32351-1731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-345-7989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY7722
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------