Provider Demographics
NPI:1922192004
Name:CLAYTON, LISA (ST)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CLAYTON
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:HETTINGER
Mailing Address - State:ND
Mailing Address - Zip Code:58639-9500
Mailing Address - Country:US
Mailing Address - Phone:701-567-2241
Mailing Address - Fax:
Practice Address - Street 1:1000 HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:HETTINGER
Practice Address - State:ND
Practice Address - Zip Code:58639-7530
Practice Address - Country:US
Practice Address - Phone:701-567-6045
Practice Address - Fax:701-567-6361
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND759235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18864OtherBLUE CROSS OF NORTH DAKOT