Healthcare Provider Details

I. General information

NPI: 1215683057
Provider Name (Legal Business Name): CAMRYN E MCCLELLAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W WARNER AVE STE 101
CHICAGO IL
60613-1891
US

IV. Provider business mailing address

1138 MAPLE AVE APT 3
EVANSTON IL
60202-4218
US

V. Phone/Fax

Practice location:
  • Phone: 312-940-2190
  • Fax:
Mailing address:
  • Phone: 623-980-7591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number00017424
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: