Provider Demographics
NPI:1114945649
Name:HANKS, CLYDE O (PHD)
Entity Type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:O
Last Name:HANKS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1438 MARLENE PL
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2907
Mailing Address - Country:US
Mailing Address - Phone:214-850-6580
Mailing Address - Fax:
Practice Address - Street 1:1438 MARLENE PL
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2907
Practice Address - Country:US
Practice Address - Phone:214-850-6580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3853106H00000X
TX24895103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131884203Medicaid
OOL86AMedicare ID - Type Unspecified