Provider Demographics
NPI:1053419945
Name:CLAY, CYNTHIA LORRAINE (MA)
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:LORRAINE
Last Name:CLAY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:CYNTHIA
Other - Middle Name:LORRAINE
Other - Last Name:DALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1005 5TH AVE STE A
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-2238
Mailing Address - Country:US
Mailing Address - Phone:304-523-9673
Mailing Address - Fax:304-523-9674
Practice Address - Street 1:1005 5TH AVE STE A
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-2238
Practice Address - Country:US
Practice Address - Phone:304-523-9673
Practice Address - Fax:304-523-9674
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV631103TB0200X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1064305000Medicaid
WV1064305000Medicaid