Provider Demographics
NPI:1609357516
Name:MCCLISTER, MANDY ELIZABETH
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:ELIZABETH
Last Name:MCCLISTER
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 1:1210 PINE MOSS CT
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581-8819
Mailing Address - Country:US
Mailing Address - Phone:281-941-9155
Mailing Address - Fax:
Practice Address - Street 1:3434 WATTERS RD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504-2015
Practice Address - Country:US
Practice Address - Phone:281-941-9155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208667224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX208667OtherLONG TERM CARE