Provider Demographics
NPI:1144627605
Name:MCLELLAN, SCOTT ALEXANDER (PTA)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:ALEXANDER
Last Name:MCLELLAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3383 E WHITMAN DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-5677
Mailing Address - Country:US
Mailing Address - Phone:208-345-3323
Mailing Address - Fax:
Practice Address - Street 1:3383 E WHITMAN DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716-5677
Practice Address - Country:US
Practice Address - Phone:208-345-3323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-28
Last Update Date:2014-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-3692225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant