Provider Demographics
NPI:1255030425
Name:CLEGG, CARLY MYERS
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:MYERS
Last Name:CLEGG
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 1:14B MARSHELLEN DR
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-6900
Mailing Address - Country:US
Mailing Address - Phone:843-400-4581
Mailing Address - Fax:843-400-4024
Practice Address - Street 1:14B MARSHELLEN DR
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-6900
Practice Address - Country:US
Practice Address - Phone:843-400-4581
Practice Address - Fax:843-400-4024
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician