Provider Demographics
NPI:1942291323
Name:CLAYBORNE, ANDRE B (EDD)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:B
Last Name:CLAYBORNE
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 S NEVADA AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2213
Mailing Address - Country:US
Mailing Address - Phone:605-361-9550
Mailing Address - Fax:605-361-9582
Practice Address - Street 1:5101 S NEVADA AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2213
Practice Address - Country:US
Practice Address - Phone:605-361-9550
Practice Address - Fax:605-361-9582
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPCMH2059101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6575380Medicaid