Basic Information
| Provider Information | |||||||||
| NPI: | 1992295018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLODFELTER | ||||||||
| FirstName: | ALLY | ||||||||
| MiddleName: | JO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21600 OXNARD ST STE 1800 | ||||||||
| Address2: | |||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913677807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183452345 | ||||||||
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| Practice Location | |||||||||
| Address1: | 711 E MAIN ST STE 14 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183452345 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2018 | ||||||||
| LastUpdateDate: | 05/14/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 3601603301512913 | TN | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.