Provider Demographics
NPI:1245565621
Name:CLANCY, KELLY MARIE (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:CLANCY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:755 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT JOY
Mailing Address - State:PA
Mailing Address - Zip Code:17552-9510
Mailing Address - Country:US
Mailing Address - Phone:717-653-0323
Mailing Address - Fax:717-653-0527
Practice Address - Street 1:755 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT JOY
Practice Address - State:PA
Practice Address - Zip Code:17552-9510
Practice Address - Country:US
Practice Address - Phone:717-653-0323
Practice Address - Fax:717-653-0527
Is Sole Proprietor?:No
Enumeration Date:2009-10-02
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT020220225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA168253R9XMedicare Oscar/Certification