Provider Demographics
NPI:1457604365
Name:MCCLELLAN, SHEMIKA A
Entity Type:Individual
Prefix:MRS
First Name:SHEMIKA
Middle Name:A
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 1:12905 161ST ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-2838
Mailing Address - Country:US
Mailing Address - Phone:718-810-9094
Mailing Address - Fax:
Practice Address - Street 1:101 NORFOLK ST FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-3301
Practice Address - Country:US
Practice Address - Phone:212-566-8855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY650038121252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency