Provider Demographics
NPI:1265815468
Name:CLANCY, ELIZABETH (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:CLANCY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15110 COPPERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-3522
Mailing Address - Country:US
Mailing Address - Phone:917-817-3496
Mailing Address - Fax:
Practice Address - Street 1:2790 N ACADEMY BLVD
Practice Address - Street 2:SUITE 227
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5337
Practice Address - Country:US
Practice Address - Phone:719-425-7771
Practice Address - Fax:719-208-7730
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-07
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0001816235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COSLP.0001816OtherLICENSE NUMBER