Provider Demographics
NPI:1023502804
Name:CLAY, BEVERLY
Entity type:Individual
Prefix:
First Name:BEVERLY
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:PO BOX 1641
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39043-1641
Mailing Address - Country:US
Mailing Address - Phone:601-616-2704
Mailing Address - Fax:769-235-1035
Practice Address - Street 1:220 OLD OAK CIR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2611
Practice Address - Country:US
Practice Address - Phone:601-616-2704
Practice Address - Fax:769-218-0011
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-15
Last Update Date:2023-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS385H00000X, 174H00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No385H00000XRespite Care FacilityRespite Care
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant