Provider Demographics
NPI:1558639971
Name:CT CLANCY MD LLC
Entity Type:Organization
Organization Name:CT CLANCY MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNBAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-954-5572
Mailing Address - Street 1:413 N ALLUMBAUGH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9212
Mailing Address - Country:US
Mailing Address - Phone:208-323-1125
Mailing Address - Fax:208-323-9604
Practice Address - Street 1:413 N ALLUMBAUGH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9212
Practice Address - Country:US
Practice Address - Phone:208-323-1125
Practice Address - Fax:208-323-9604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-114792084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty