Doctor Name: | CHARLES SANFORD CLYDE |
NPI Number: | 1174680995 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | LPC |
License Number: | |
Business Practice Address: | 125 N Ruby Ln Fairview Heights, IL - 622081926 |
Business Phone Number: | 6183984226 |
Business Fax Number: | 6183981759 |
Mailing Address: | 125 N Ruby Ln, FAIRVIEW HEIGHTS |
State: | IL |
Postal Code: | 622081926 |
Phone Number: | 6183984226 |
Fax Number: | 6183981759 |
NPI Enumeration Date: | 01/02/2007 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YP2500X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | IL |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Professional |
Taxonomy Definition: |