Provider Demographics
NPI:1972910552
Name:MCCLELLAND, TRISTA (MA LPC NCC)
Entity type:Individual
Prefix:
First Name:TRISTA
Middle Name:
Last Name:MCCLELLAND
Suffix:
Gender:F
Credentials:MA LPC NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 RUSSELL ST APT 1
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2930
Mailing Address - Country:US
Mailing Address - Phone:906-869-1809
Mailing Address - Fax:
Practice Address - Street 1:710 CHIPPEWA SQUARE
Practice Address - Street 2:SUITE 206
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855
Practice Address - Country:US
Practice Address - Phone:906-225-3145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012673101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional