Provider Demographics
NPI:1700043445
Name:MCCLURE, MARY MICHAL (MSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MICHAL
Last Name:MCCLURE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:MICHAL
Other - Last Name:HAATVEDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:2213 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5305
Mailing Address - Country:US
Mailing Address - Phone:515-237-3974
Mailing Address - Fax:515-883-2692
Practice Address - Street 1:600 42ND ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-2701
Practice Address - Country:US
Practice Address - Phone:515-255-8399
Practice Address - Fax:515-255-8405
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02528104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1001123Medicaid
IA0469676Medicaid