Healthcare Provider Details

I. General information

NPI: 1326118415
Provider Name (Legal Business Name): STEPHEN M MCCLELLAN P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5194 HIGHWAY 100 SUITE 105
LYLES TN
37098-2821
US

IV. Provider business mailing address

5194 HIGHWAY 100 SUITE 105
LYLES TN
37098-2821
US

V. Phone/Fax

Practice location:
  • Phone: 931-670-6161
  • Fax: 931-670-6355
Mailing address:
  • Phone: 931-670-6161
  • Fax: 931-670-6355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT3001
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: