Provider Demographics
NPI:1255617361
Name:MCCLELLAN, GAIL COOPER (AT,C)
Entity type:Individual
Prefix:MRS
First Name:GAIL
Middle Name:COOPER
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6088 SOUTHWARD AVE
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-1436
Mailing Address - Country:US
Mailing Address - Phone:248-802-6542
Mailing Address - Fax:
Practice Address - Street 1:32 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-1526
Practice Address - Country:US
Practice Address - Phone:248-922-9001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010000512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer