Provider Demographics
NPI:1457978264
Name:CLAYTON, BRYAN KEVIN (CPSS,MH,SA)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:KEVIN
Last Name:CLAYTON
Suffix:
Gender:M
Credentials:CPSS,MH,SA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1515
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-1515
Mailing Address - Country:US
Mailing Address - Phone:336-647-4384
Mailing Address - Fax:
Practice Address - Street 1:210 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-4904
Practice Address - Country:US
Practice Address - Phone:336-647-4384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2018-5396-01101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)