Provider Demographics
NPI:1487725107
Name:MCLEN, JOHN RUSSELL (MMFY)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:RUSSELL
Last Name:MCLEN
Suffix:
Gender:M
Credentials:MMFY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1166 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79601-5831
Mailing Address - Country:US
Mailing Address - Phone:325-676-8963
Mailing Address - Fax:325-676-2915
Practice Address - Street 1:1166 N 3RD ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-5831
Practice Address - Country:US
Practice Address - Phone:325-676-8963
Practice Address - Fax:325-676-2915
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1684106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173BOtherBLUE CROSS