Provider Demographics
NPI:1699898486
Name:MACCLELLAN, LOUANN (OTR)
Entity type:Individual
Prefix:
First Name:LOUANN
Middle Name:
Last Name:MACCLELLAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 COUNTY ROAD 310
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-9470
Mailing Address - Country:US
Mailing Address - Phone:386-328-4713
Mailing Address - Fax:
Practice Address - Street 1:405 S. SUMMIT ST.
Practice Address - Street 2:UNIT F
Practice Address - City:CRESCENT CITY
Practice Address - State:FL
Practice Address - Zip Code:32112-3031
Practice Address - Country:US
Practice Address - Phone:386-698-4720
Practice Address - Fax:386-698-4866
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT1893225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist