Healthcare Provider Details

I. General information

NPI: 1245730910
Provider Name (Legal Business Name): CHRISTOPHER ANDREW CLAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2018
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1072 S DIXIE BLVD
RADCLIFF KY
40160-1103
US

IV. Provider business mailing address

107 CRANES ROOST CT
ELIZABETHTOWN KY
42701-3650
US

V. Phone/Fax

Practice location:
  • Phone: 270-351-8166
  • Fax: 270-351-8322
Mailing address:
  • Phone: 270-765-2605
  • Fax: 270-234-8572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number272176
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: