MEDICARE: MISS MARY JANE CLOW LCDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	13607	TX

General Provider Information

NPI Number	:	1841001435
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MARY JANE CLOW LCDC

Provider Business Mailing Address
First Line	:	17206 SPRINGFIELD DR
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77302-7106
Country	:	US
Telephone Number	:	346-560-0507
Fax Number	:

Provider Business Practice Location Address
First Line	:	4322 HERRIDGE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77022-3945
Country	:	US
Telephone Number	:	281-310-0956
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/14/2025
Last Update Date	:	01/14/2025

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Directions to “ MISS MARY JANE CLOW LCDC” Practice Location

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