Provider Demographics
NPI:1043724024
Name:MCCLELLAN, KEVIN WESLEY (PT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:WESLEY
Last Name:MCCLELLAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 S UNION AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1950
Mailing Address - Country:US
Mailing Address - Phone:253-759-1310
Mailing Address - Fax:253-759-1330
Practice Address - Street 1:1802 S UNION AVE STE 100
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1950
Practice Address - Country:US
Practice Address - Phone:253-759-1310
Practice Address - Fax:253-759-1330
Is Sole Proprietor?:No
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60785802225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist