Provider Demographics
NPI:1164188694
Name:MUSSELMAN, CLAY MICHAEL
Entity Type:Individual
Prefix:
First Name:CLAY
Middle Name:MICHAEL
Last Name:MUSSELMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MONTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-2176
Mailing Address - Country:US
Mailing Address - Phone:740-586-1566
Mailing Address - Fax:
Practice Address - Street 1:164 NURSING HOME CIR
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-3117
Practice Address - Country:US
Practice Address - Phone:706-745-4948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OTA002829224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOTA002829Medicaid