Provider Demographics
NPI:1851962294
Name:MCLELLAN, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:MCLELLAN
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 1:19019 STATE HIGHWAY 71 W
Mailing Address - Street 2:
Mailing Address - City:SPICEWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:78669-6468
Mailing Address - Country:US
Mailing Address - Phone:512-646-9789
Mailing Address - Fax:
Practice Address - Street 1:19019 STATE HIGHWAY 71 W
Practice Address - Street 2:
Practice Address - City:SPICEWOOD
Practice Address - State:TX
Practice Address - Zip Code:78669-6468
Practice Address - Country:US
Practice Address - Phone:512-646-9789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
TX6412103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician