Healthcare Provider Details

I. General information

NPI: 1003453200
Provider Name (Legal Business Name): MACKENZIE MCCLELLAN TLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2019
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8150 E 13 MILE RD
WARREN MI
48093-8700
US

IV. Provider business mailing address

6549 TOWN CENTER DR STE A
CLARKSTON MI
48346-4824
US

V. Phone/Fax

Practice location:
  • Phone: 586-825-9700
  • Fax:
Mailing address:
  • Phone: 248-620-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301018169
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: