Provider Demographics
NPI:1346842614
Name:MCCLELLAND, MACKENZIE ELIZABETH-ROSE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ELIZABETH-ROSE
Last Name:MCCLELLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:634 E GREENLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-3307
Mailing Address - Country:US
Mailing Address - Phone:517-643-4997
Mailing Address - Fax:
Practice Address - Street 1:771 CHESTNUT RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-3434
Practice Address - Country:US
Practice Address - Phone:517-353-4412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty