Healthcare Provider Details

I. General information

NPI: 1205793510
Provider Name (Legal Business Name): GAVIN DALE MCCLELLAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2026
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 N 500 W
PROVO UT
84604-3380
US

IV. Provider business mailing address

893 N 900 E
PLEASANT GROVE UT
84062-1904
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-7850
  • Fax:
Mailing address:
  • Phone: 801-822-7699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: