Provider Demographics
NPI:1477220481
Name:MCCLELLAN, KIRT PATRICK
Entity Type:Individual
Prefix:
First Name:KIRT
Middle Name:PATRICK
Last Name:MCCLELLAN
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 1:694 NE 76TH ST APT 9
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33138-5143
Mailing Address - Country:US
Mailing Address - Phone:305-613-1431
Mailing Address - Fax:
Practice Address - Street 1:694 NE 76TH ST APT 9
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33138-5143
Practice Address - Country:US
Practice Address - Phone:305-613-1431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW69921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical