Provider Demographics
NPI:1740016468
Name:MCCLELLAN, KIMBERLY DIANE
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DIANE
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 1:227 EAGLE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MOYOCK
Mailing Address - State:NC
Mailing Address - Zip Code:27958-9365
Mailing Address - Country:US
Mailing Address - Phone:252-548-0713
Mailing Address - Fax:
Practice Address - Street 1:1421 KRISTINA WAY
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-8917
Practice Address - Country:US
Practice Address - Phone:757-547-0153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool