Provider Demographics
NPI:1306481411
Name:MCCLELLAN, MCKENZIE B (BCBA)
Entity type:Individual
Prefix:MRS
First Name:MCKENZIE
Middle Name:B
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:MCKENZIE
Other - Middle Name:L
Other - Last Name:BOVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:F7 STONEHEDGE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7368
Mailing Address - Country:US
Mailing Address - Phone:802-345-1745
Mailing Address - Fax:
Practice Address - Street 1:174 AVENUE C
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-7840
Practice Address - Country:US
Practice Address - Phone:662-783-1802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1-19-37321103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1025330Medicaid