Provider Demographics
NPI:1053440479
Name:MACLELLAN, MARY ANNE (MA, CCC, SLP)
Entity Type:Individual
Prefix:
First Name:MARY ANNE
Middle Name:
Last Name:MACLELLAN
Suffix:
Gender:F
Credentials:MA, CCC, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1595 GRAND AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-2450
Mailing Address - Country:US
Mailing Address - Phone:760-471-1198
Mailing Address - Fax:760-471-5657
Practice Address - Street 1:1595 GRAND AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-2450
Practice Address - Country:US
Practice Address - Phone:760-471-1198
Practice Address - Fax:760-471-5657
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP4920235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASP0049200Medicaid