Provider Demographics
NPI:1164647228
Name:MCCLELLAN, TRACY L (LMP)
Entity Type:Individual
Prefix:MISS
First Name:TRACY
Middle Name:L
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 OCEAN BEACH HWY
Mailing Address - Street 2:SP. #12
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-5080
Mailing Address - Country:US
Mailing Address - Phone:360-577-7191
Mailing Address - Fax:
Practice Address - Street 1:401 N PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-3515
Practice Address - Country:US
Practice Address - Phone:360-577-7191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020641225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist