Provider Demographics
NPI:1891764544
Name:CLENDENIN, MARY ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:CLENDENIN
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:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-0188
Mailing Address - Country:US
Mailing Address - Phone:520-682-4111
Mailing Address - Fax:
Practice Address - Street 1:899 N WILMOT RD STE B
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-1712
Practice Address - Country:US
Practice Address - Phone:520-290-1100
Practice Address - Fax:520-290-8997
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC73631041C0700X
AZLCSW-128461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ571662Medicaid