1881704708 NPI number — DR. MICHELLE LYNNE MCCLELLAN PSY D

Table of content: DR. MICHELLE LYNNE MCCLELLAN PSY D (NPI 1881704708)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881704708 NPI number — DR. MICHELLE LYNNE MCCLELLAN PSY D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCLELLAN
Provider First Name:
MICHELLE
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FLIGGER
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1881704708
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 WEST TERRA COTTA AVE #9
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRYSTAL LAKE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-254-0654
Provider Business Mailing Address Fax Number:
815-479-9146

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 WEST TERRA COTTA AVE #9
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRYSTAL LAKE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-254-0654
Provider Business Practice Location Address Fax Number:
815-479-9146
Provider Enumeration Date:
08/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  2778-57 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 071-006469 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 0.71006469 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: 4245 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)