Provider Demographics
NPI:1902388531
Name:CLAY, LAKEISHA LASHON MARIE
Entity Type:Individual
Prefix:
First Name:LAKEISHA
Middle Name:LASHON MARIE
Last Name:CLAY
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 1:1700 E CENTRAL TEXAS EXPY UNIT 300-A
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76541-9115
Mailing Address - Country:US
Mailing Address - Phone:254-531-0500
Mailing Address - Fax:
Practice Address - Street 1:1711 E CENTRAL TEXAS EXPY STE 300A
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76541-9147
Practice Address - Country:US
Practice Address - Phone:254-531-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician