Provider Demographics
NPI:1407066319
Name:REDD, CLYDE L JR (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:L
Last Name:REDD
Suffix:JR
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-4934
Mailing Address - Country:US
Mailing Address - Phone:937-878-1141
Mailing Address - Fax:
Practice Address - Street 1:331 N BROAD ST
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-4934
Practice Address - Country:US
Practice Address - Phone:937-878-1141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1918237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist