Provider Demographics
NPI:1407853625
Name:MCLELLAN, MARY JANE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JANE
Last Name:MCLELLAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 W KILTIE LN
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-9107
Mailing Address - Country:US
Mailing Address - Phone:928-774-3086
Mailing Address - Fax:928-213-8507
Practice Address - Street 1:2415 W KILTIE LN
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-9107
Practice Address - Country:US
Practice Address - Phone:928-774-3086
Practice Address - Fax:928-213-8507
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3087103T00000X
VA1077103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ361650Medicaid