Provider Demographics
NPI:1891179453
Name:CLAYTON, CHAQULLA
Entity Type:Individual
Prefix:
First Name:CHAQULLA
Middle Name:
Last Name:CLAYTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 ROZIER SIDING RD
Mailing Address - Street 2:
Mailing Address - City:SAINT PAULS
Mailing Address - State:NC
Mailing Address - Zip Code:28384-6971
Mailing Address - Country:US
Mailing Address - Phone:910-740-6425
Mailing Address - Fax:
Practice Address - Street 1:642 ROZIER SIDING RD
Practice Address - Street 2:
Practice Address - City:SAINT PAULS
Practice Address - State:NC
Practice Address - Zip Code:28384-6971
Practice Address - Country:US
Practice Address - Phone:910-740-6425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0109631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical