Provider Demographics
NPI:1598043689
Name:MCCLAIN, MARILYN
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:MCCLAIN
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:PO BOX 51882
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92517-2882
Mailing Address - Country:US
Mailing Address - Phone:951-653-9894
Mailing Address - Fax:
Practice Address - Street 1:5005 LA MART DR
Practice Address - Street 2:#100 B9
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-5952
Practice Address - Country:US
Practice Address - Phone:909-559-0923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-24
Last Update Date:2011-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 261511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical