Healthcare Provider Details

I. General information

NPI: 1417381203
Provider Name (Legal Business Name): SHAWN MICHAEL MCCLINTOCK PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2013
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5323 HARRY HINES BOULEVARD
DALLAS TX
75390-7208
US

IV. Provider business mailing address

P.O. BOX 845347
DALLAS TX
75284-5347
US

V. Phone/Fax

Practice location:
  • Phone: 214-645-8300
  • Fax: 214-645-4871
Mailing address:
  • Phone: 214-645-8300
  • Fax: 214-645-4871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4455
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number36143
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number36143
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: