Healthcare Provider Details

I. General information

NPI: 1083477186
Provider Name (Legal Business Name): EMMANUEL MCCLELLAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6770 CINCINNATI DAYTON RD STE 208
LIBERTY TOWNSHIP OH
45044-9318
US

IV. Provider business mailing address

7001 ASHWOOD CT
SPRINGBORO OH
45066-9196
US

V. Phone/Fax

Practice location:
  • Phone: 513-712-5146
  • Fax:
Mailing address:
  • Phone: 937-475-0908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2507294
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: