Provider Demographics
NPI:1871129833
Name:WAMPLER, CLINTON DOUGLAS
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:DOUGLAS
Last Name:WAMPLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CLINT
Other - Middle Name:DOUGLAS
Other - Last Name:WAMPLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:15116 N COTTON LN
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-9618
Mailing Address - Country:US
Mailing Address - Phone:800-376-3440
Mailing Address - Fax:
Practice Address - Street 1:15116 N COTTON LN
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85388-9618
Practice Address - Country:US
Practice Address - Phone:800-376-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-20
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician