Provider Demographics
NPI:1245820943
Name:MCCLELLAN, AMANDA ANN
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ANN
Last Name:MCCLELLAN
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 1:3300 JAMES ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13206-2392
Mailing Address - Country:US
Mailing Address - Phone:154-220-3003
Mailing Address - Fax:315-479-8455
Practice Address - Street 1:3300 JAMES ST STE 100
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13206-2392
Practice Address - Country:US
Practice Address - Phone:154-220-3003
Practice Address - Fax:315-479-8455
Is Sole Proprietor?:No
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006665101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health