Provider Demographics
NPI:1487717336
Name:MCLELLAN III, THOMAS G (LSW)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:G
Last Name:MCLELLAN III
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 TAMARACK DR
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:PA
Mailing Address - Zip Code:15126-1155
Mailing Address - Country:US
Mailing Address - Phone:412-389-1642
Mailing Address - Fax:
Practice Address - Street 1:615 E MCMURRAY RD
Practice Address - Street 2:
Practice Address - City:MCMURRAY
Practice Address - State:PA
Practice Address - Zip Code:15317-3497
Practice Address - Country:US
Practice Address - Phone:724-942-3996
Practice Address - Fax:724-942-2571
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW012708L1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASW012708LOtherSOCIAL WORK LICENSE