Provider Demographics
NPI:1770123499
Name:MCLELLAN, GINA M (DPT)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:MCLELLAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 CENTERVILLE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-4376
Mailing Address - Country:US
Mailing Address - Phone:401-737-6011
Mailing Address - Fax:401-737-4811
Practice Address - Street 1:594 GREAT RD
Practice Address - Street 2:
Practice Address - City:NORTH SMITHFIELD
Practice Address - State:RI
Practice Address - Zip Code:02896-6810
Practice Address - Country:US
Practice Address - Phone:401-597-5840
Practice Address - Fax:401-597-5840
Is Sole Proprietor?:No
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA24385225100000X
RIPT03194225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist