Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | 6301018169 | MI |
Y | 103TC0700X | Clinical Psychologist | 6301018169 | MI |
NPI | 1003453200 |
---|---|
Provider Name | Mackenzie Mcclellan |
First Address | Clarkston, MI 48346-4824 |
Second Address | Warren, MI 48093-8700 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/12/2019 |
Last Update Date | 06/12/2019 |