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NPI Code Detail

MEDICARE: MR. KELLY RICHARD MCCLANAHAN RADT

MEDICARE: MR. KELLY RICHARD MCCLANAHAN RADT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YA0400XAddiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number : 1265918833
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. KELLY RICHARD MCCLANAHAN RADT
Provider Business Mailing Address
First Line : 1081 CAMINO DEL RIO S STE 129
Second Line :
City : SAN DIEGO
State : CA
Zip : 92108-3544
Country : US
Telephone Number : 619-297-5131
Fax Number : 619-296-3846
Provider Business Practice Location Address
First Line : 4161 MARLBOROUGH AVE
Second Line :
City : SAN DIEGO
State : CA
Zip : 92105-1412
Country : US
Telephone Number : 619-282-7274
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/17/2018
Last Update Date : 07/17/2018

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