Provider Demographics
NPI:1801650759
Name:CLAYTON, OMNI-ROSE
Entity type:Individual
Prefix:
First Name:OMNI-ROSE
Middle Name:
Last Name:CLAYTON
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 1:6655 SANTA BARBARA RD UNIT 8574
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-7523
Mailing Address - Country:US
Mailing Address - Phone:866-610-0580
Mailing Address - Fax:
Practice Address - Street 1:809 WHITE OAKS LN
Practice Address - Street 2:
Practice Address - City:POCOMOKE CITY
Practice Address - State:MD
Practice Address - Zip Code:21851-9589
Practice Address - Country:US
Practice Address - Phone:410-726-3548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP14735101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional