Provider Demographics
NPI:1992039804
Name:CLANCY, KRISTA MARIE
Entity Type:Individual
Prefix:MS
First Name:KRISTA
Middle Name:MARIE
Last Name:CLANCY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 ST. ANTOINE UHC 6F MAILBOX# 226
Mailing Address - Street 2:UNIVERSITY PEDIATRICIANS
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201
Mailing Address - Country:US
Mailing Address - Phone:313-966-5051
Mailing Address - Fax:
Practice Address - Street 1:41935 12 MILE RD.
Practice Address - Street 2:CHRILDREN'S HOSPITAL OF MI AUTISM CENTER
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377
Practice Address - Country:US
Practice Address - Phone:248-305-6211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-24
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011361103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical