Basic Information
| Provider Information | |||||||||
| NPI: | 1679769996 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCLINTOCK | ||||||||
| FirstName: | KELLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 LUMBER ST. | ||||||||
| Address2: | |||||||||
| City: | LITTLESTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7174516945 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10435 DOWNSVILLE PIKE | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217407901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017668222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2007 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OC007194L | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 05171 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 101421547 | 01 | PA | MA | OTHER |