Basic Information
| Provider Information | |||||||||
| NPI: | 1336668698 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLAYSTONE CLINICAL ASSOCIATES PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2040 RAYBROOK ST SE STE 300 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495467718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169497460 | ||||||||
| FaxNumber: | 6169493018 | ||||||||
| Practice Location | |||||||||
| Address1: | 2040 RAYBROOK ST SE STE 300 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495467718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169497460 | ||||||||
| FaxNumber: | 6169493018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | FARIDI | ||||||||
| AuthorizedOfficialFirstName: | TARIQ | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6169497460 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.