Healthcare Provider Details

I. General information

NPI: 1821009275
Provider Name (Legal Business Name): MRS. SUSAN DIANE CLANCY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 BRECKSVILLE RD
BRECKSVILLE OH
44141-3204
US

IV. Provider business mailing address

6015 WILD OAK DR
NORTH OLMSTED OH
44070-3817
US

V. Phone/Fax

Practice location:
  • Phone: 440-526-3030
  • Fax:
Mailing address:
  • Phone: 440-777-4403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: