Provider Demographics
NPI:1205892148
Name:CLANCY-LEVAN, KATHERINE MAURA (MSPT)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:MAURA
Last Name:CLANCY-LEVAN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 PARK PL
Mailing Address - Street 2:SUITE D
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2184
Mailing Address - Country:US
Mailing Address - Phone:856-256-8393
Mailing Address - Fax:856-256-8390
Practice Address - Street 1:14 PARK PL
Practice Address - Street 2:SUITE D
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2184
Practice Address - Country:US
Practice Address - Phone:856-256-8393
Practice Address - Fax:856-256-8390
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00883000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA073598Medicare ID - Type Unspecified