Provider Demographics
NPI:1508410614
Name:MCCLELLAN, MARY MILLER
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:MILLER
Last Name:MCCLELLAN
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 1:17 BURGEE CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7342
Mailing Address - Country:US
Mailing Address - Phone:803-546-9942
Mailing Address - Fax:
Practice Address - Street 1:4214 HARD SCRABBLE RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-8560
Practice Address - Country:US
Practice Address - Phone:803-546-9942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care