Basic Information
Provider Information | |||||||||
NPI: | 1265516595 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUTROW | ||||||||
FirstName: | M.CLAIRE | ||||||||
MiddleName: | H | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC,LMFT,CSAC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7969 ASHTON AVE | ||||||||
Address2: |   | ||||||||
City: | MANASSAS | ||||||||
State: | VA | ||||||||
PostalCode: | 201092885 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7037927800 | ||||||||
FaxNumber: | 7037925699 | ||||||||
Practice Location | |||||||||
Address1: | 7969 ASHTON AVE | ||||||||
Address2: |   | ||||||||
City: | MANASSAS | ||||||||
State: | VA | ||||||||
PostalCode: | 201092885 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7037927800 | ||||||||
FaxNumber: | 7037925699 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2006 | ||||||||
LastUpdateDate: | 05/19/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0710001126 | VA | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 0701002668 | VA | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | 0717000694 | VA | N |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 004978277 | 05 | VA |   | MEDICAID | 210245 | 01 | VA | BLUE CROSS BLUE SHIELD | OTHER | 004945247 | 05 | VA |   | MEDICAID |