Provider Demographics
NPI:1609399229
Name:CLARY, MAMIE MAE (MA BCBA)
Entity Type:Individual
Prefix:MS
First Name:MAMIE
Middle Name:MAE
Last Name:CLARY
Suffix:
Gender:F
Credentials:MA BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14722 NACOGDOCHES RD APT 1114
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-4521
Mailing Address - Country:US
Mailing Address - Phone:210-807-2271
Mailing Address - Fax:
Practice Address - Street 1:14722 NACOGDOCHES RD APT 1114
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-4521
Practice Address - Country:US
Practice Address - Phone:210-807-2271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-17-26486103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst