Provider Demographics
NPI:1548649320
Name:CLANCY, KATHLEEN (MS CCC SLP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:CLANCY
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 202
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98073-0202
Mailing Address - Country:US
Mailing Address - Phone:425-326-8383
Mailing Address - Fax:
Practice Address - Street 1:6611 159TH AVE NE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-4813
Practice Address - Country:US
Practice Address - Phone:425-326-8383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-26
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15963235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALL 60575085OtherSTATE CREDENTIAL
CASP 15963OtherSTATE LICENSE