Provider Demographics
NPI:1619148376
Name:MCCLAIN, TRISTAN MARIE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:TRISTAN
Middle Name:MARIE
Last Name:MCCLAIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 CHARLIE RD
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:SC
Mailing Address - Zip Code:29657-9693
Mailing Address - Country:US
Mailing Address - Phone:864-346-3219
Mailing Address - Fax:864-482-0072
Practice Address - Street 1:10626 CLEMSON BLVD
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-4526
Practice Address - Country:US
Practice Address - Phone:864-482-0085
Practice Address - Fax:864-482-0072
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1965225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant