Provider Demographics
NPI:1174702302
Name:WAYLAND, CLOTIE (LCSW)
Entity type:Individual
Prefix:
First Name:CLOTIE
Middle Name:
Last Name:WAYLAND
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 1:12431 MARDI GRAS DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77014-2484
Mailing Address - Country:US
Mailing Address - Phone:832-423-2708
Mailing Address - Fax:
Practice Address - Street 1:9525 KATY FWY STE 312
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-1467
Practice Address - Country:US
Practice Address - Phone:713-343-2622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX166921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124282805Medicaid
TX00S32QMedicare PIN