Provider Demographics
NPI:1871293985
Name:MCCLAIN, MAURICE
Entity type:Individual
Prefix:
First Name:MAURICE
Middle Name:
Last Name:MCCLAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 265
Mailing Address - Street 2:
Mailing Address - City:SHELL LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54871-0265
Mailing Address - Country:US
Mailing Address - Phone:715-468-2841
Mailing Address - Fax:
Practice Address - Street 1:3712 TOWER AVE STE C
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5397
Practice Address - Country:US
Practice Address - Phone:715-468-2841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5411-226101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
5411-226OtherLICENSE