Provider Demographics
NPI:1790099026
Name:CLANCY, MOLLY C (DPT)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:C
Last Name:CLANCY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:C
Other - Last Name:SHULA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4570
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85261-4570
Mailing Address - Country:US
Mailing Address - Phone:480-551-4961
Mailing Address - Fax:480-860-0356
Practice Address - Street 1:1907 W CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-3439
Practice Address - Country:US
Practice Address - Phone:602-285-0949
Practice Address - Fax:602-285-0052
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9004225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ549943Medicaid
AZZ140646Medicare PIN