Healthcare Provider Details

I. General information

NPI: 1578703559
Provider Name (Legal Business Name): CRYSTAL CLANCY MA, LMFT, PMH-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14665 GALAXIE AVE STE 140
APPLE VALLEY MN
55124-4509
US

IV. Provider business mailing address

14665 GALAXIE AVE STE 140
APPLE VALLEY MN
55124-4509
US

V. Phone/Fax

Practice location:
  • Phone: 651-456-8494
  • Fax:
Mailing address:
  • Phone: 651-456-8494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1592
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: