Provider Demographics
NPI:1326387192
Name:COULTER, CLYDE JEROME JR
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:JEROME
Last Name:COULTER
Suffix:JR
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 1:9800 NE 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-1507
Mailing Address - Country:US
Mailing Address - Phone:405-706-6945
Mailing Address - Fax:
Practice Address - Street 1:9800 NE 10TH ST
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-1507
Practice Address - Country:US
Practice Address - Phone:405-706-6945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKP080460188101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional