Healthcare Provider Details

I. General information

NPI: 1548915788
Provider Name (Legal Business Name): DEIDRE ODETTE MCCLELLAN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2022
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 E 25TH ST
BALTIMORE MD
21218-5213
US

IV. Provider business mailing address

7402 MAURY RD
WINDSOR MILL MD
21244-4009
US

V. Phone/Fax

Practice location:
  • Phone: 410-558-0032
  • Fax:
Mailing address:
  • Phone: 443-253-2236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number28224
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: