Provider Demographics
NPI:1578703559
Name:CLANCY, CRYSTAL (MA, LMFT, PMH-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:CLANCY
Suffix:
Gender:F
Credentials:MA, LMFT, PMH-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W BURNSVILLE PKWY STE 207
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-0010
Mailing Address - Country:US
Mailing Address - Phone:612-548-4266
Mailing Address - Fax:
Practice Address - Street 1:101 W BURNSVILLE PKWY STE 207
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-0010
Practice Address - Country:US
Practice Address - Phone:612-548-4266
Practice Address - Fax:952-686-6966
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-03
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1592106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1578703559Medicaid