Healthcare Provider Details

I. General information

NPI: 1942455837
Provider Name (Legal Business Name): KATHLEEN MARY CLANCY LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2008
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BANK ST SUITE 306
SEYMOUR CT
06483-2806
US

IV. Provider business mailing address

100 BANK ST SUITE 306
SEYMOUR CT
06483-2806
US

V. Phone/Fax

Practice location:
  • Phone: 203-888-0462
  • Fax: 203-888-1465
Mailing address:
  • Phone: 203-888-0462
  • Fax: 203-888-1465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number96302
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number001294
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: