Provider Demographics
NPI:1780120196
Name:CLAYTON, MARK II
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CLAYTON
Suffix:II
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 1:9948 S PARNELL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-1231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9948 S PARNELL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-1231
Practice Address - Country:US
Practice Address - Phone:310-968-2068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-09
Last Update Date:2023-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6835101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional