Basic Information
Provider Information
NPI: 1477531622
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MCLELLAN
FirstName: WENDY
MiddleName: M
NamePrefix: MRS.
NameSuffix:  
Credential: MA, LCDP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 32 SWEENEY LN
Address2:  
City: BRISTOL
State: RI
PostalCode: 028094223
CountryCode: US
TelephoneNumber: 4012542569
FaxNumber:  
Practice Location
Address1: 2 OLD COUNTY RD
Address2:  
City: BARRINGTON
State: RI
PostalCode: 028061602
CountryCode: US
TelephoneNumber: 4012461195
FaxNumber:  
Other Information
ProviderEnumerationDate: 01/06/2006
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: X
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YA0400XLCDP00131RIY Behavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)

No ID Information.


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