1104954114 NPI number — MATTHEW D. CLAYTON LSCSW, LCMFT

Table of content: KJERSTI MARIE AAGAARD-TILLERY MD (NPI 1033299938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104954114 NPI number — MATTHEW D. CLAYTON LSCSW, LCMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLAYTON
Provider First Name:
MATTHEW
Provider Middle Name:
D.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LSCSW, LCMFT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104954114
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
217 KANSAS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLTON
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66436-1538
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-364-6561
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 SW GAGE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOPEKA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66604-3340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-272-0778
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  4091 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 106H00000X , with the licence number: LCMFT684 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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