Provider Demographics
NPI:1437996048
Name:MCLEAN, KANDISS SHANELL
Entity type:Individual
Prefix:
First Name:KANDISS
Middle Name:SHANELL
Last Name:MCLEAN
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 1:1102 BAINBRIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23523-1309
Mailing Address - Country:US
Mailing Address - Phone:757-339-0744
Mailing Address - Fax:
Practice Address - Street 1:1102 BAINBRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23523-1309
Practice Address - Country:US
Practice Address - Phone:757-339-0744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health