Provider Demographics
NPI:1104375963
Name:MCCLURE, BYRON (SSP, NCSP)
Entity Type:Individual
Prefix:
First Name:BYRON
Middle Name:
Last Name:MCCLURE
Suffix:
Gender:M
Credentials:SSP, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2641 LACROSSE PL
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-3871
Mailing Address - Country:US
Mailing Address - Phone:301-442-2447
Mailing Address - Fax:
Practice Address - Street 1:3231 SUPERIOR LN
Practice Address - Street 2:SUITE A6
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-1923
Practice Address - Country:US
Practice Address - Phone:301-464-5129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08-6200103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool