Provider Demographics
NPI:1316176860
Name:SANDFORD, CLYDE WILLIAM (LPC)
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:WILLIAM
Last Name:SANDFORD
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 703
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-0014
Mailing Address - Country:US
Mailing Address - Phone:603-801-9392
Mailing Address - Fax:
Practice Address - Street 1:169 DEMPSEY AVE STE 3
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-2019
Practice Address - Country:US
Practice Address - Phone:401-889-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-06
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC011574106H00000X, 101Y00000X, 101YA0400X, 101YM0800X, 101YP1600X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH81263595Medicaid