Provider Demographics
NPI:1366591240
Name:GLANDON, CLYDE CALVIN (DMIN)
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:CALVIN
Last Name:GLANDON
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4223 E 84TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-1820
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2761 E SKELLY DR
Practice Address - Street 2:SUITE 700
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-6232
Practice Address - Country:US
Practice Address - Phone:918-747-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1597101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1597OtherLICENSED PROFESSIONAL COU