Basic Information
| Provider Information | |||||||||
| NPI: | 1649315201 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLAY | ||||||||
| FirstName: | INDRIA | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | LCSW | ||||||||
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| OtherLastName: | CLAY | ||||||||
| OtherFirstName: | INDRIA | ||||||||
| OtherMiddleName: | F | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 211 REED CIR | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383559818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316608781 | ||||||||
| FaxNumber: | 7316608739 | ||||||||
| Practice Location | |||||||||
| Address1: | 1125 6TH ST SE | ||||||||
| Address2: | |||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562014675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202354613 | ||||||||
| FaxNumber: | 8556257406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 07/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6516 | TN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.