Provider Demographics
NPI:1689603904
Name:CLANCY, SALLY O (PT)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:O
Last Name:CLANCY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1016
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5221
Mailing Address - Country:US
Mailing Address - Phone:662-238-2800
Mailing Address - Fax:662-238-2808
Practice Address - Street 1:2205 JEFFERSON DAVIS DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5221
Practice Address - Country:US
Practice Address - Phone:662-238-2800
Practice Address - Fax:662-238-2808
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3472225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126119Medicaid
MS650000339Medicare ID - Type Unspecified