Provider Demographics
NPI:1467569657
Name:RUTLAND, MARY (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:RUTLAND
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3633 CAMINO DEL RIO SOUTH
Mailing Address - Street 2:STE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4004
Mailing Address - Country:US
Mailing Address - Phone:619-284-4700
Mailing Address - Fax:619-260-8288
Practice Address - Street 1:3633 CAMINO DEL RIO SOUTH
Practice Address - Street 2:STE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4004
Practice Address - Country:US
Practice Address - Phone:619-284-4700
Practice Address - Fax:619-260-8288
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW46061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCSW4606OtherLICENSE NUMBER
CASW4606Medicare PIN