Provider Demographics
NPI:1184416109
Name:MCLELLAN, BRENDA ANNETTE
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:ANNETTE
Last Name:MCLELLAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3031 MAYFAIR DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4269
Mailing Address - Country:US
Mailing Address - Phone:509-552-7157
Mailing Address - Fax:
Practice Address - Street 1:1370 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2332
Practice Address - Country:US
Practice Address - Phone:509-780-8840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-19
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-565225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist