Provider Demographics
NPI:1497262588
Name:MCLEAN, WANDA YVETTE
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:YVETTE
Last Name:MCLEAN
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 1:3639 OLD PETERSBURG RD APT B
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2866
Mailing Address - Country:US
Mailing Address - Phone:706-306-8565
Mailing Address - Fax:
Practice Address - Street 1:620 PONDER PLACE DR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3118
Practice Address - Country:US
Practice Address - Phone:706-993-6404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT008329225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist