Provider Demographics
NPI:1366718314
Name:MCCLELLAN, GREGORY LAMONT (PT)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:LAMONT
Last Name:MCCLELLAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 RANSOM RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3617
Mailing Address - Country:US
Mailing Address - Phone:336-479-5221
Mailing Address - Fax:
Practice Address - Street 1:515 RANSOM RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3617
Practice Address - Country:US
Practice Address - Phone:336-479-5221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-23
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8007401922251H1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251H1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHuman Factors