Provider Demographics
NPI:1619156601
Name:MCLELLAN, CHARLES HUGH
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:HUGH
Last Name:MCLELLAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3637 MISSION AVE BLDG B
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-2946
Mailing Address - Country:US
Mailing Address - Phone:916-485-4175
Mailing Address - Fax:
Practice Address - Street 1:3637 MISSION AVE BLDG B
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608
Practice Address - Country:US
Practice Address - Phone:916-485-4175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-26
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program