Provider Demographics
NPI:1003189747
Name:DALEY, CLOVIS EVERET (LICSW)
Entity Type:Individual
Prefix:
First Name:CLOVIS
Middle Name:EVERET
Last Name:DALEY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17102 EAGLE HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:AQUASCO
Mailing Address - State:MD
Mailing Address - Zip Code:20608-9566
Mailing Address - Country:US
Mailing Address - Phone:301-266-0340
Mailing Address - Fax:
Practice Address - Street 1:17102 EAGLE HARBOR RD
Practice Address - Street 2:
Practice Address - City:AQUASCO
Practice Address - State:MD
Practice Address - Zip Code:20608-9566
Practice Address - Country:US
Practice Address - Phone:301-266-0340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC50079299171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator