Provider Demographics
NPI:1750794012
Name:MCCLELLAN, RACHAEL R (RDN)
Entity type:Individual
Prefix:MS
First Name:RACHAEL
Middle Name:R
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:RACHAEL
Other - Middle Name:R
Other - Last Name:MCCLELLAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CPT
Mailing Address - Street 1:37637 FIVE MILE RD # 110
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-1543
Mailing Address - Country:US
Mailing Address - Phone:224-829-7522
Mailing Address - Fax:
Practice Address - Street 1:35475 FIVE MILE RD RM 2
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-2366
Practice Address - Country:US
Practice Address - Phone:224-829-7522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-04
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86028218133NN1002X, 174H00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1750794012Medicaid