MEDICARE: MS. BONNIE L MCCLELLAN

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

General Provider Information

NPI Number	:	1528189107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BONNIE L MCCLELLAN

Provider Business Mailing Address
First Line	:	2107 STEWART ST
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95205-3227
Country	:	US
Telephone Number	:	209-953-7303
Fax Number	:	209-468-8640

Provider Business Practice Location Address
First Line	:	620 N AURORA ST STE 1
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95202-2276
Country	:	US
Telephone Number	:	209-953-7303
Fax Number	:	209-468-8640

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

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	07/08/2007

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