MEDICARE: SHADALIA TIAYEL MCCLEAN LCSW

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
1	1041C0700X	Clinical Social Worker	0904015538	VA

General Provider Information

NPI Number	:	1851073795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHADALIA TIAYEL MCCLEAN LCSW

Provider Business Mailing Address
First Line	:	15500 PARKGATE DR
Second Line	:
City	:	CHESTER
State	:	VA
Zip	:	23831-7389
Country	:	US
Telephone Number	:	804-892-1739
Fax Number	:

Provider Business Practice Location Address
First Line	:	15500 PARKGATE DR
Second Line	:
City	:	CHESTER
State	:	VA
Zip	:	23831-7389
Country	:	US
Telephone Number	:	804-892-1739
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2023
Last Update Date	:	08/01/2023

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