Provider Demographics
NPI:1649744301
Name:CLAY, TERRY MATTHEW
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:MATTHEW
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 1:311 N HAMILTON ST
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:TX
Mailing Address - Zip Code:78629-4005
Mailing Address - Country:US
Mailing Address - Phone:830-263-2750
Mailing Address - Fax:830-672-8481
Practice Address - Street 1:1110 N SARAH DEWITT DR
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:TX
Practice Address - Zip Code:78629-3311
Practice Address - Country:US
Practice Address - Phone:830-672-7581
Practice Address - Fax:830-672-8481
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1131514225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1131514OtherPT LICENSE