Provider Demographics
NPI:1821108853
Name:PICH, CLYDE JAMES JR (PT)
Entity Type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:JAMES
Last Name:PICH
Suffix:JR
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 1:549 EAST 6TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090
Mailing Address - Country:US
Mailing Address - Phone:636-390-9067
Mailing Address - Fax:
Practice Address - Street 1:2022 PHOENIX DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090
Practice Address - Country:US
Practice Address - Phone:636-239-9979
Practice Address - Fax:636-239-5442
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1999140691225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist