Basic Information
| Provider Information | |||||||||
| NPI: | 1326069964 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VAGCVHCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7125 RICHMOND DR | ||||||||
| Address2: | |||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395324045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2283928439 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 VETERANS AVE | ||||||||
| Address2: | |||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395312410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2285235000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CLAYTON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PSYCHIATRIST/ACTING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2285235000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 5595 | MS | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.