Provider Demographics
NPI:1346581386
Name:CLAY, WALLACE
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:
Last Name:CLAY
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 1:11428 E 20TH ST
Mailing Address - Street 2:UNIT A
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74128-6451
Mailing Address - Country:US
Mailing Address - Phone:918-878-7877
Mailing Address - Fax:
Practice Address - Street 1:11428 E 20TH ST
Practice Address - Street 2:UNIT A
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74128-6451
Practice Address - Country:US
Practice Address - Phone:918-878-7877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK000000000Medicaid