Provider Demographics
NPI:1417771106
Name:CLODFELTER, TRISTAN
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:CLODFELTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 W MAIN ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-4312
Mailing Address - Country:US
Mailing Address - Phone:828-315-0049
Mailing Address - Fax:
Practice Address - Street 1:7374 CREIGHTON PKWY
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23111-4615
Practice Address - Country:US
Practice Address - Phone:804-410-1195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704017527101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor