Healthcare Provider Details

I. General information

NPI: 1194378307
Provider Name (Legal Business Name): MARY MCLELLAN, LCSW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PASEO DE PERALTA #204
SANTA FE NM
87501-8750
US

IV. Provider business mailing address

PO BOX 71654
OAKLAND CA
94612
US

V. Phone/Fax

Practice location:
  • Phone: 505-660-3580
  • Fax:
Mailing address:
  • Phone: 505-660-3580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. MARY MCLELLAN
Title or Position: LCSW
Credential:
Phone: 505-660-3580