Provider Demographics
NPI:1982310520
Name:FARROW, CLYDE H
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:H
Last Name:FARROW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 CLAYSTONE RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-2552
Mailing Address - Country:US
Mailing Address - Phone:915-867-1563
Mailing Address - Fax:
Practice Address - Street 1:912 CLAYSTONE RIDGE AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89084-2552
Practice Address - Country:US
Practice Address - Phone:915-867-1563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1405852726Medicaid