Provider Demographics
NPI:1124310008
Name:CLAYCON, LLC
Entity type:Organization
Organization Name:CLAYCON, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-280-5758
Mailing Address - Street 1:8829 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-2610
Mailing Address - Country:US
Mailing Address - Phone:662-280-5758
Mailing Address - Fax:662-280-5708
Practice Address - Street 1:5158 STAGE RD
Practice Address - Street 2:SUITE 130
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-3116
Practice Address - Country:US
Practice Address - Phone:662-280-5758
Practice Address - Fax:662-280-5708
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLAYCON LLC DBA: A BRIDGE TO RECOVERY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty