Provider Demographics
NPI:1053083774
Name:CLANTON, CHARLEY MARIE BENEFIELD (LBA)
Entity Type:Individual
Prefix:
First Name:CHARLEY
Middle Name:MARIE BENEFIELD
Last Name:CLANTON
Suffix:
Gender:F
Credentials:LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5110 MARYLAND WAY STE 320
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7591
Mailing Address - Country:US
Mailing Address - Phone:614-588-9544
Mailing Address - Fax:
Practice Address - Street 1:5110 MARYLAND WAY STE 320
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-7591
Practice Address - Country:US
Practice Address - Phone:614-588-9544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN847103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst