Provider Demographics
NPI:1881893865
Name:CLANCY, LISA ANN (PT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:CLANCY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2954 FLAMELIGHT CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-2413
Mailing Address - Country:US
Mailing Address - Phone:314-845-6719
Mailing Address - Fax:
Practice Address - Street 1:2954 FLAMELIGHT CT
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-2413
Practice Address - Country:US
Practice Address - Phone:314-845-6719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO01623OtherPT LICENSE