Provider Demographics
NPI:1457605727
Name:MCLELLAN, MARY R (LMSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:MCLELLAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:EL CENTRO FAMILLY HEALTH
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-0158
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:505-753-5815
Practice Address - Street 1:1331 GUSDORF RD
Practice Address - Street 2:EL CENTRO FAMILLY HEALTH-TAOS CLINIC
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6282
Practice Address - Country:US
Practice Address - Phone:575-758-3601
Practice Address - Fax:575-758-1058
Is Sole Proprietor?:No
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMM-08004104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker