Provider Demographics
NPI:1285653360
Name:DAISS, CLIFFORD GARY (MED)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:GARY
Last Name:DAISS
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 288
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-0288
Mailing Address - Country:US
Mailing Address - Phone:605-348-5401
Mailing Address - Fax:605-348-7319
Practice Address - Street 1:528 QUINCY ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-3628
Practice Address - Country:US
Practice Address - Phone:605-348-5401
Practice Address - Fax:605-348-7319
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1780104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7100070Medicaid
SD4062Medicare ID - Type Unspecified