MEDICARE: DIANNA CLAYTON LPC

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	101Y00000X	Counselor	66078	TX
2	101YM0800X	Mental Health Counselor	66078	TX
3	101YP2500X	Professional Counselor	66078	TX

General Provider Information

NPI Number	:	1275993982
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANNA CLAYTON LPC

Provider Business Mailing Address
First Line	:	189 BRYSON RIDGE DR
Second Line	:
City	:	BOWIE
State	:	TX
Zip	:	76230-8530
Country	:	US
Telephone Number	:	940-781-5310
Fax Number	:

Provider Business Practice Location Address
First Line	:	5751 PARK VISTA CIR STE 101
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5607
Country	:	US
Telephone Number	:	817-812-2880
Fax Number	:

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

Provider Enumeration Date	:	02/24/2016
Last Update Date	:	06/14/2016

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