MEDICARE: DR. CLYDE FRANKLIN TRUAN III PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	000921	GA

General Provider Information

NPI Number	:	1104093632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLYDE FRANKLIN TRUAN III PH.D.

Provider Business Mailing Address
First Line	:	2465 DEMERE RD
Second Line	:	SUITE 209
City	:	ST SIMONS ISLAND
State	:	GA
Zip	:	31522-1630
Country	:	US
Telephone Number	:	912-399-5414
Fax Number	:	912-267-7981

Provider Business Practice Location Address
First Line	:	2465 DEMERE RD
Second Line	:	SUITE 209
City	:	ST SIMONS ISLAND
State	:	GA
Zip	:	31522-1630
Country	:	US
Telephone Number	:	912-399-5414
Fax Number	:	912-267-7981

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2008
Last Update Date	:	05/14/2008

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