Provider Demographics
NPI:1538734694
Name:CLAY, TINA
Entity type:Individual
Prefix:MS
First Name:TINA
Middle Name:
Last Name:CLAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 BOONE CT
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-4695
Mailing Address - Country:US
Mailing Address - Phone:707-761-3307
Mailing Address - Fax:
Practice Address - Street 1:TEACH ACQUIRE THRIVE
Practice Address - Street 2:2010-A HARBISON DR. STE 307
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687
Practice Address - Country:US
Practice Address - Phone:707-317-1517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABACB666793106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician