Provider Demographics
NPI:1346805066
Name:MCCLAIN, MARYELLEN KATHERINE BRUNSON (PHD-LP)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:KATHERINE BRUNSON
Last Name:MCCLAIN
Suffix:
Gender:F
Credentials:PHD-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6410 OLD MAIN HL
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84322-6410
Mailing Address - Country:US
Mailing Address - Phone:435-797-1346
Mailing Address - Fax:844-308-5865
Practice Address - Street 1:6405 OLD MAIN HILL
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84322-0001
Practice Address - Country:US
Practice Address - Phone:435-797-1346
Practice Address - Fax:844-308-5865
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10464447-2501OtherLICENSE