Provider Demographics
NPI:1235619917
Name:MCCLANAHAN, CULLENA JILL (MS)
Entity Type:Individual
Prefix:
First Name:CULLENA
Middle Name:JILL
Last Name:MCCLANAHAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 LEFT FORK ELK CRK
Mailing Address - Street 2:
Mailing Address - City:DELBARTON
Mailing Address - State:WV
Mailing Address - Zip Code:25670-7340
Mailing Address - Country:US
Mailing Address - Phone:540-420-8881
Mailing Address - Fax:304-475-2011
Practice Address - Street 1:41 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3201
Practice Address - Country:US
Practice Address - Phone:304-235-3390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV403Medicaid