Provider Demographics
NPI:1619692878
Name:BINGHAM, CLEON CLINT
Entity Type:Individual
Prefix:
First Name:CLEON
Middle Name:CLINT
Last Name:BINGHAM
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 1:8096 NW 21ST CT
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33322-3931
Mailing Address - Country:US
Mailing Address - Phone:954-579-9121
Mailing Address - Fax:
Practice Address - Street 1:8096 NW 21ST CT
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33322-3931
Practice Address - Country:US
Practice Address - Phone:954-579-9121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-172233106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111017500Medicaid