Provider Demographics
NPI:1194378307
Name:MARY MCLELLAN, LCSW
Entity Type:Organization
Organization Name:MARY MCLELLAN, LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCLELLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-660-3580
Mailing Address - Street 1:PO BOX 71654
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612
Mailing Address - Country:US
Mailing Address - Phone:505-660-3580
Mailing Address - Fax:
Practice Address - Street 1:300 PASEO DE PERALTA
Practice Address - Street 2:#204
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-8750
Practice Address - Country:US
Practice Address - Phone:505-660-3580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty