Provider Demographics
NPI:1881680916
Name:CLAYTON, DORTHY C (MSW LCSW)
Entity Type:Individual
Prefix:MS
First Name:DORTHY
Middle Name:C
Last Name:CLAYTON
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:MISS
Other - First Name:DORTHY
Other - Middle Name:MARIE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:300 W ANDERSON ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-2141
Mailing Address - Country:US
Mailing Address - Phone:208-523-8721
Mailing Address - Fax:208-523-8721
Practice Address - Street 1:300 W ANDERSON ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-2141
Practice Address - Country:US
Practice Address - Phone:208-523-8721
Practice Address - Fax:208-523-8721
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW545101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDL5451OtherBLUE CROSS
ID000010015878OtherREGENCE BLUE SHIELD
ID1690114Medicare ID - Type Unspecified