Provider Demographics
NPI:1689082927
Name:SELF, CLAYTON (PT)
Entity Type:Individual
Prefix:
First Name:CLAYTON
Middle Name:
Last Name:SELF
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805B SUMMERHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-6082
Mailing Address - Country:US
Mailing Address - Phone:252-312-7250
Mailing Address - Fax:
Practice Address - Street 1:310 S MCCASKEY RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:NC
Practice Address - Zip Code:27892-2150
Practice Address - Country:US
Practice Address - Phone:252-809-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP15099225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist