Provider Demographics
NPI:1063110450
Name:CLAY, KENDALL
Entity type:Individual
Prefix:
First Name:KENDALL
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 1:13717 REESE BLVD W APT 304
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-6087
Mailing Address - Country:US
Mailing Address - Phone:910-604-4589
Mailing Address - Fax:
Practice Address - Street 1:311 WILLIAMSON RD STE 103
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5967
Practice Address - Country:US
Practice Address - Phone:704-360-3049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18465101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional