Provider Demographics
NPI:1316223639
Name:MCLELLAN, WARREN G
Entity Type:Individual
Prefix:MR
First Name:WARREN
Middle Name:G
Last Name:MCLELLAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 540
Mailing Address - Street 2:
Mailing Address - City:FORK
Mailing Address - State:MD
Mailing Address - Zip Code:21051-0540
Mailing Address - Country:US
Mailing Address - Phone:410-570-7045
Mailing Address - Fax:
Practice Address - Street 1:2717 GREENE RD
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:MD
Practice Address - Zip Code:21013-9108
Practice Address - Country:US
Practice Address - Phone:410-570-7045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA444101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)