Provider Demographics
NPI:1285836130
Name:MCLIN, MARY JO (PSYD)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:MCLIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3516 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-8757
Mailing Address - Country:US
Mailing Address - Phone:501-812-5352
Mailing Address - Fax:
Practice Address - Street 1:4400 SHUFFIELD DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7100
Practice Address - Country:US
Practice Address - Phone:501-686-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR98-8P103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR98-8POtherPSYCHOLOGIST LICENSE NUMB
AR5U053Medicare PIN