Provider Demographics
NPI:1699101337
Name:MCCLENNEN, SANDRA (LP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:MCCLENNEN
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 N SHELDON RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1046
Mailing Address - Country:US
Mailing Address - Phone:734-453-6857
Mailing Address - Fax:734-453-1454
Practice Address - Street 1:7800 W OUTER DR STE 300
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3458
Practice Address - Country:US
Practice Address - Phone:313-340-4442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301001694103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities