Provider Demographics
NPI:1285879361
Name:CLYBURN, THOMAS WILLIAM III (PHD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WILLIAM
Last Name:CLYBURN
Suffix:III
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4501 MANATEE AVE W # 209
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-3952
Mailing Address - Country:US
Mailing Address - Phone:941-224-3800
Mailing Address - Fax:941-745-1630
Practice Address - Street 1:318 OLD MAIN ST
Practice Address - Street 2:SUITE 21
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-7819
Practice Address - Country:US
Practice Address - Phone:941-224-3800
Practice Address - Fax:941-745-1630
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-03
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7314101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health