Provider Demographics
NPI:1023609815
Name:MCCLELLAN, CAMISHA D (LAT, ATC)
Entity type:Individual
Prefix:
First Name:CAMISHA
Middle Name:D
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1517 STONELEIGH CT APT 1098
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76011-2796
Mailing Address - Country:US
Mailing Address - Phone:940-228-9492
Mailing Address - Fax:
Practice Address - Street 1:1517 STONELEIGH CT APT 1098
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-2796
Practice Address - Country:US
Practice Address - Phone:940-228-9492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer