MEDICARE: ANDRE B CLAYBORNE EDD

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	101YM0800X	Mental Health Counselor	LPCMH2059	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942291323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDRE B CLAYBORNE EDD

Provider Business Mailing Address
First Line	:	5101 S NEVADA AVE
Second Line	:	SUITE 120
City	:	SIOUX FALLS
State	:	SD
Zip	:	57108-2213
Country	:	US
Telephone Number	:	605-361-9550
Fax Number	:	605-361-9582

Provider Business Practice Location Address
First Line	:	5101 S NEVADA AVE
Second Line	:	SUITE 120
City	:	SIOUX FALLS
State	:	SD
Zip	:	57108-2213
Country	:	US
Telephone Number	:	605-361-9550
Fax Number	:	605-361-9582

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

Provider Enumeration Date	:	11/03/2005
Last Update Date	:	08/16/2011

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