Provider Demographics
NPI:1649242843
Name:THURMOND, CLARENCE WADE (LCSW)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:WADE
Last Name:THURMOND
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-2244
Mailing Address - Country:US
Mailing Address - Phone:706-542-9700
Mailing Address - Fax:706-227-7249
Practice Address - Street 1:250 NORTH AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-2244
Practice Address - Country:US
Practice Address - Phone:706-542-9739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0010051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA80BBCQJMedicare ID - Type Unspecified