Provider Demographics
NPI:1518418631
Name:MCCLELLAN, LUEBERTHA
Entity Type:Individual
Prefix:
First Name:LUEBERTHA
Middle Name:
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 1:15346 DEXTER AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-2127
Mailing Address - Country:US
Mailing Address - Phone:313-870-8770
Mailing Address - Fax:
Practice Address - Street 1:15346 DEXTER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-2127
Practice Address - Country:US
Practice Address - Phone:313-870-8770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other