Provider Demographics
NPI:1275665234
Name:CLANCY, KELLY ANN (OTRL, CHT, RBT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:CLANCY
Suffix:
Gender:F
Credentials:OTRL, CHT, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3323 NW 71ST ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98117-6146
Mailing Address - Country:US
Mailing Address - Phone:206-508-1265
Mailing Address - Fax:206-508-1265
Practice Address - Street 1:2821 NW MARKET ST STE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-5815
Practice Address - Country:US
Practice Address - Phone:206-508-1265
Practice Address - Fax:206-508-1265
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2009-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00001887225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA602-669-365OtherUBI WASHINGTON STATE
611805700OtherFEDERAL LABOR AND INDUSTR
WA4020-CLOtherREGENCE
WA0207147OtherSTATE LABOR AND INDUSTRIE
262169551OtherFEDERAL TAX ID