Provider Demographics
NPI:1649331109
Name:CLANCY, ANGELA RUTH (LCPC)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:RUTH
Last Name:CLANCY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:586 S CLANCY DR
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-7171
Mailing Address - Country:US
Mailing Address - Phone:208-664-0284
Mailing Address - Fax:208-664-8828
Practice Address - Street 1:212 S 11TH ST
Practice Address - Street 2:STE5
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4000
Practice Address - Country:US
Practice Address - Phone:208-664-0284
Practice Address - Fax:208-664-8828
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-330101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID431973380OtherEIN