Provider Demographics
NPI:1588259543
Name:CLAY, DICK (HIS)
Entity type:Individual
Prefix:
First Name:DICK
Middle Name:
Last Name:CLAY
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3704
Mailing Address - Country:US
Mailing Address - Phone:618-624-4471
Mailing Address - Fax:
Practice Address - Street 1:3552 S CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5183
Practice Address - Country:US
Practice Address - Phone:417-864-4327
Practice Address - Fax:417-864-4327
Is Sole Proprietor?:No
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002024064237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist