Provider Demographics
NPI:1568131712
Name:CLAYTON, ANGELIA (LCDC-III)
Entity Type:Individual
Prefix:
First Name:ANGELIA
Middle Name:
Last Name:CLAYTON
Suffix:
Gender:F
Credentials:LCDC-III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 12TH ST SW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44647-6383
Mailing Address - Country:US
Mailing Address - Phone:330-209-8165
Mailing Address - Fax:
Practice Address - Street 1:106 12TH ST SW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44647-6383
Practice Address - Country:US
Practice Address - Phone:330-209-8165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-10
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.162634101YA0400X
OHCDCA.182609101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0461340Medicaid
1568131712OtherNPI