1184240616 NPI number — DR. DEBRA WALKER MCCLENDON PHD

Table of content: DR. DEBRA WALKER MCCLENDON PHD (NPI 1184240616)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184240616 NPI number — DR. DEBRA WALKER MCCLENDON PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCLENDON
Provider First Name:
DEBRA
Provider Middle Name:
WALKER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184240616
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1093 CALLE CARRILLO
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIMAS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91773-4300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-374-7935
Provider Business Mailing Address Fax Number:
909-575-6717

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 PIERRE RD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALNUT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91789-2565
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-374-7935
Provider Business Practice Location Address Fax Number:
909-575-6717
Provider Enumeration Date:
06/20/2020

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: 246Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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