Basic Information
| Provider Information | |||||||||
| NPI: | 1871952747 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMS | ||||||||
| FirstName: | CLAYTON | ||||||||
| MiddleName: | LENNON | ||||||||
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| Mailing Information | |||||||||
| Address1: | N27W23957 PAUL RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PEWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530726223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622784462 | ||||||||
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| Practice Location | |||||||||
| Address1: | N27W23957 PAUL RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PEWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530726223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622784462 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2016 | ||||||||
| LastUpdateDate: | 02/19/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 15618131 | WY | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 15618131 | 01 | WI | STATE LICENSE | OTHER |