Provider Demographics
NPI:1588280390
Name:MCCLELLAN, MADISON (DPT)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12844 COLDWATER RD STE B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-8833
Mailing Address - Country:US
Mailing Address - Phone:260-497-7191
Mailing Address - Fax:260-497-7791
Practice Address - Street 1:10006 AUBURN PARK DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-2389
Practice Address - Country:US
Practice Address - Phone:260-497-7191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013739A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist