Basic Information
| Provider Information | |||||||||
| NPI: | 1376671933 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCLELLAN | ||||||||
| FirstName: | CHERYL | ||||||||
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| Credential: | SW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3501 MOON ST NE | ||||||||
| Address2: | MADISON MS | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871114619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052994735 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3501 MOON ST NE | ||||||||
| Address2: | MADISON MS | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871114619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052994735 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | M 2619 | NM | X | Behavioral Health & Social Service Providers | Social Worker | 1041S0200X | M 2619 | NM | X | Behavioral Health & Social Service Providers | Social Worker | School |
ID Information
| ID | Type | State | Issuer | Description | 83127089 | 05 | NM | MEDICAID |