Provider Demographics
NPI:1952438889
Name:MCCLAIN, THERON GLEN (SAC)
Entity Type:Individual
Prefix:
First Name:THERON
Middle Name:GLEN
Last Name:MCCLAIN
Suffix:
Gender:M
Credentials:SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3708 MIRAGE DR
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-9416
Mailing Address - Country:US
Mailing Address - Phone:951-443-2470
Mailing Address - Fax:
Practice Address - Street 1:960 N STATE ST STE B
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-1473
Practice Address - Country:US
Practice Address - Phone:951-652-3560
Practice Address - Fax:951-929-2780
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1807Medicaid