Healthcare Provider Details

I. General information

NPI: 1366865719
Provider Name (Legal Business Name): MCLAULIN PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2014
Last Update Date: 01/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

283 MILTON LN
WAVERLY GA
31565-1931
US

IV. Provider business mailing address

283 MILTON LN
WAVERLY GA
31565-1931
US

V. Phone/Fax

Practice location:
  • Phone: 215-284-8434
  • Fax:
Mailing address:
  • Phone: 215-284-8434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number022248
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number022248
License Number StateGA

VIII. Authorized Official

Name: DR. JOHN BRYCE MCLAULIN
Title or Position: OWNER
Credential: M. D.
Phone: 215-284-8434