Healthcare Provider Details

I. General information

NPI: 1528088226
Provider Name (Legal Business Name): CHARLES CLANCY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ZORN AVE
LOUISVILLE KY
40206-1433
US

IV. Provider business mailing address

12225 CROSSWINDS DR
LOUISVILLE KY
40243-2111
US

V. Phone/Fax

Practice location:
  • Phone: 502-287-6196
  • Fax: 502-287-6197
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number943
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: