Provider Demographics
NPI:1679769996
Name:MCCLINTOCK, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MCCLINTOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 LUMBER ST.
Mailing Address - Street 2:
Mailing Address - City:LITTLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17340
Mailing Address - Country:US
Mailing Address - Phone:717-451-6945
Mailing Address - Fax:
Practice Address - Street 1:10435 DOWNSVILLE PIKE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-7901
Practice Address - Country:US
Practice Address - Phone:301-766-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC007194L225X00000X
MD05171225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101421547OtherMA