MEDICARE: MS. MARY RUTLAND LCSW

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	1041C0700X	Clinical Social Worker	LCSW4606	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LCSW4606	OTHER	CA	LICENSE NUMBER

General Provider Information

NPI Number	:	1467569657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY RUTLAND LCSW

Provider Business Mailing Address
First Line	:	3633 CAMINO DEL RIO SOUTH
Second Line	:	STE 200
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-4004
Country	:	US
Telephone Number	:	619-284-4700
Fax Number	:	619-260-8288

Provider Business Practice Location Address
First Line	:	3633 CAMINO DEL RIO SOUTH
Second Line	:	STE 200
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-4004
Country	:	US
Telephone Number	:	619-284-4700
Fax Number	:	619-260-8288

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

Provider Enumeration Date	:	08/24/2006
Last Update Date	:	05/21/2008

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