Healthcare Provider Details

I. General information

NPI: 1376682732
Provider Name (Legal Business Name): EDWARD CARL VANDER CLUTE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 ROWLAND WAY STE 220
NOVATO CA
94945-5039
US

IV. Provider business mailing address

75 ROWLAND WAY STE 220
NOVATO CA
94945-5039
US

V. Phone/Fax

Practice location:
  • Phone: 628-336-5460
  • Fax: 628-240-2141
Mailing address:
  • Phone: 628-336-5460
  • Fax: 628-240-2141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW19489
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: