Provider Demographics
NPI:1760712293
Name:MCLELLAN, EILEEN F (LICSW)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:F
Last Name:MCLELLAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CREAMERY BROOK RD
Mailing Address - Street 2:
Mailing Address - City:DANBY
Mailing Address - State:VT
Mailing Address - Zip Code:05739-9782
Mailing Address - Country:US
Mailing Address - Phone:802-779-7346
Mailing Address - Fax:
Practice Address - Street 1:128 MERCHANTS ROW
Practice Address - Street 2:STE 512
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-5911
Practice Address - Country:US
Practice Address - Phone:802-779-7346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900613441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1017187Medicaid