Provider Demographics
NPI:1093240418
Name:CLANCY, KATHLEEN MOORE (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:MOORE
Last Name:CLANCY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1056 CINDER HILL WAY
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-1498
Mailing Address - Country:US
Mailing Address - Phone:609-420-7412
Mailing Address - Fax:
Practice Address - Street 1:1056 CINDER HILL WAY
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-1498
Practice Address - Country:US
Practice Address - Phone:609-420-7412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-23
Last Update Date:2017-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12774PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist