Provider Demographics
NPI:1467560078
Name:CLUTE, MARY JANE (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:CLUTE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:
Other - Last Name:CLUTE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW,PA
Mailing Address - Street 1:113 ROBERTS CIR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-1960
Mailing Address - Country:US
Mailing Address - Phone:512-244-0900
Mailing Address - Fax:512-244-0908
Practice Address - Street 1:400 W MAIN AVE
Practice Address - Street 2:STE. 219
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-5808
Practice Address - Country:US
Practice Address - Phone:512-244-0900
Practice Address - Fax:512-244-0908
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX401711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0082LJOtherBCBS
TX251328OtherCOMPSYCH
TX00452XMedicare ID - Type Unspecified