Provider Demographics
NPI:1841497252
Name:MCLELLAN, CHRISTINE GUTBERLET (COTA)
Entity type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:GUTBERLET
Last Name:MCLELLAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 572
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:WA
Mailing Address - Zip Code:98353-0572
Mailing Address - Country:US
Mailing Address - Phone:360-871-4468
Mailing Address - Fax:
Practice Address - Street 1:140 S MARION AVE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-3639
Practice Address - Country:US
Practice Address - Phone:360-479-4747
Practice Address - Fax:360-478-6246
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOCOOOOO929224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4111589OtherMCD
WA505240Medicare ID - Type Unspecified
WA1780756932Medicare UPIN