Healthcare Provider Details

I. General information

NPI: 1346276292
Provider Name (Legal Business Name): MICHAEL W CLANCY LCPC, LCADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10630 LITTLE PATUXENT PKWY SUITE 209
COLUMBIA MD
21044-3273
US

IV. Provider business mailing address

10630 LITTLE PATUXENT PKWY SUITE 209
COLUMBIA MD
21044-3264
US

V. Phone/Fax

Practice location:
  • Phone: 410-740-8066
  • Fax: 410-740-8068
Mailing address:
  • Phone: 410-740-8066
  • Fax: 410-740-8068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCA323
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC1210
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: