Provider Demographics
NPI:1538646641
Name:MCCLELLAN, SARA JANE (CDCA)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:JANE
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:686 STATE ROUTE 7 NE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44403-9663
Mailing Address - Country:US
Mailing Address - Phone:330-601-9788
Mailing Address - Fax:
Practice Address - Street 1:686 STATE ROUTE 7 NE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:OH
Practice Address - Zip Code:44403-9663
Practice Address - Country:US
Practice Address - Phone:330-601-9788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-20
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.168824101YA0400X
OH164882324500000X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGMedicaid