Basic Information
| Provider Information | |||||||||
| NPI: | 1164705695 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLAYTON | ||||||||
| FirstName: | GRETCHEN | ||||||||
| MiddleName: | LEANE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WRAY | ||||||||
| OtherFirstName: | GRETCHEN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 100 N ROCKINGCHAIR RD STE 1-3 | ||||||||
| Address2: | |||||||||
| City: | PARAGOULD | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724502413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703359617 | ||||||||
| FaxNumber: | 8703359618 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N ROCKINGCHAIR RD STE 1-3 | ||||||||
| Address2: | |||||||||
| City: | PARAGOULD | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724502413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703359617 | ||||||||
| FaxNumber: | 8703359618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2011 | ||||||||
| LastUpdateDate: | 09/21/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | P1103017 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.