Provider Demographics
NPI:1821502261
Name:MCCLAM, VANESSA (PTA)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:MCCLAM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4280 TRINITY MILLS RD APT 605
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-7624
Mailing Address - Country:US
Mailing Address - Phone:954-559-9228
Mailing Address - Fax:561-907-4958
Practice Address - Street 1:4280 TRINITY MILLS RD APT 605
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75287-7624
Practice Address - Country:US
Practice Address - Phone:954-559-9228
Practice Address - Fax:561-907-4958
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA21225225200000X
TX2087130225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant