Provider Demographics
NPI:1962923474
Name:GALLON CLYBURN, VERNICE DOLORES (LRT/CTRS)
Entity type:Individual
Prefix:
First Name:VERNICE
Middle Name:DOLORES
Last Name:GALLON CLYBURN
Suffix:
Gender:F
Credentials:LRT/CTRS
Other - Prefix:
Other - First Name:VERNICE
Other - Middle Name:DOLORES
Other - Last Name:GALLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:126 S ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083-3552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:126 S ROSE AVE
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083-3552
Practice Address - Country:US
Practice Address - Phone:704-938-9657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-06
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19360225800000X
NC1702225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation TherapistGroup - Single Specialty