Provider Demographics
NPI:1184893778
Name:MCKELLAR, JOHN DAVIS (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVIS
Last Name:MCKELLAR
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:15047 LOS GATOS BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-2054
Mailing Address - Country:US
Mailing Address - Phone:408-364-6799
Mailing Address - Fax:408-378-4510
Practice Address - Street 1:15047 LOS GATOS BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-2054
Practice Address - Country:US
Practice Address - Phone:408-364-6799
Practice Address - Fax:408-378-4510
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18966103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA122627Medicare PIN