Provider Demographics
NPI:1932835931
Name:MACLELLAN, MATTHEW SCOTT
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:SCOTT
Last Name:MACLELLAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:SCOTT
Other - Last Name:CRISAMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4125 TEMESCAL ST STE A&C
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-7558
Mailing Address - Country:US
Mailing Address - Phone:916-877-6894
Mailing Address - Fax:
Practice Address - Street 1:4125 TEMESCAL ST STE A&C
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-7558
Practice Address - Country:US
Practice Address - Phone:916-877-6894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty