Provider Demographics
NPI:1326118415
Name:MCCLELLAN, STEPHEN M (PT)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:M
Last Name:MCCLELLAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5194 HIGHWAY 100
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LYLES
Mailing Address - State:TN
Mailing Address - Zip Code:37098-2821
Mailing Address - Country:US
Mailing Address - Phone:931-670-6161
Mailing Address - Fax:931-670-6355
Practice Address - Street 1:5194 HIGHWAY 100
Practice Address - Street 2:SUITE 105
Practice Address - City:LYLES
Practice Address - State:TN
Practice Address - Zip Code:37098-2821
Practice Address - Country:US
Practice Address - Phone:931-670-6161
Practice Address - Fax:931-670-6355
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT3001225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN32-0024304OtherTAX ID
TN32-0024304OtherTAX ID