Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101Y00000X | Counselor | LPC011574 | GA |
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | LPC011574 | GA |
N | 101YM0800X | Mental Health Counselor | LPC011574 | GA |
N | 101YP1600X | Pastoral Counselor | LPC011574 | GA |
Y | 101YP2500X | Professional Counselor | LPC011574 | GA |
NPI | 1316176860 |
---|---|
Provider Name | Clyde William Sandford |
First Address | Mcdonough, GA 30253-4310 |
Second Address | Mcdonough, GA 30253-4310 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2009 |
Last Update Date | 07/07/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
81263595 | (05) | NH |