Provider Demographics
NPI:1487045217
Name:MACLELLAN, MATTHEW (TLLP)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MACLELLAN
Suffix:
Gender:M
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 W BIG BEAVER RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-3545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 W BIG BEAVER RD
Practice Address - Street 2:SUITE 150
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3545
Practice Address - Country:US
Practice Address - Phone:248-918-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-16
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016821103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist