Provider Demographics
NPI:1063743771
Name:MCCLELLAN, GERALD STANLEY (BCBA)
Entity type:Individual
Prefix:MR
First Name:GERALD
Middle Name:STANLEY
Last Name:MCCLELLAN
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 PHEASANT COVE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:YARMOUTH PORT
Mailing Address - State:MA
Mailing Address - Zip Code:02675-1022
Mailing Address - Country:US
Mailing Address - Phone:860-930-1348
Mailing Address - Fax:
Practice Address - Street 1:41 PHEASANT COVE CIRCLE
Practice Address - Street 2:
Practice Address - City:YARMOUTH PORT
Practice Address - State:MA
Practice Address - Zip Code:02675-1022
Practice Address - Country:US
Practice Address - Phone:860-930-1348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-20
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-02-1013103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst