Provider Demographics
NPI:1811009517
Name:MCLELLARN, ROBERT W (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:MCLELLARN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5440 SW WESTGATE DR
Mailing Address - Street 2:#175
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2420
Mailing Address - Country:US
Mailing Address - Phone:503-297-3334
Mailing Address - Fax:503-297-5744
Practice Address - Street 1:5440 SW WESTGATE DR
Practice Address - Street 2:#175
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2420
Practice Address - Country:US
Practice Address - Phone:503-297-3334
Practice Address - Fax:503-297-5744
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR634103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000TCHFKMedicare ID - Type Unspecified