Provider Demographics
NPI:1770036295
Name:MCCLOUD, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MCCLOUD
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 1:1514 VERNON RD
Mailing Address - Street 2:WELLSTAR WEST GEORGIA MEDICAL CENTER - REHAB SERVICES
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4131
Mailing Address - Country:US
Mailing Address - Phone:706-845-3862
Mailing Address - Fax:706-845-3700
Practice Address - Street 1:1514 VERNON RD
Practice Address - Street 2:WELLSTAR WEST GEORGIA MEDICAL CENTER - REHAB SERVICES
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4131
Practice Address - Country:US
Practice Address - Phone:706-845-3862
Practice Address - Fax:706-845-3700
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1092235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist