Provider Demographics
NPI:1831359397
Name:MCLEAN, ELISSA LOUISE (MSPT)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:LOUISE
Last Name:MCLEAN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:ELLIE
Other - Middle Name:LOUISE
Other - Last Name:MCLEAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:700 S LA POSADA CIR
Mailing Address - Street 2:
Mailing Address - City:GREEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85614-5100
Mailing Address - Country:US
Mailing Address - Phone:520-648-8380
Mailing Address - Fax:
Practice Address - Street 1:700 S LA POSADA CIR
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614-5100
Practice Address - Country:US
Practice Address - Phone:520-648-8380
Practice Address - Fax:520-648-8116
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6952225100000X
TX1170461225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ169622Medicare PIN