Healthcare Provider Details

I. General information

NPI: 1780917617
Provider Name (Legal Business Name): CLANCY J. YEAGER PCC-S, LICDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2009
Last Update Date: 09/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27072 CARRONADE DR. SUITE A
PERRYSBURG OH
43551
US

IV. Provider business mailing address

PO BOX 29 BEHAVIORAL CONNECTIONS
BOWLING GREEN OH
43402
US

V. Phone/Fax

Practice location:
  • Phone: 419-872-2419
  • Fax: 419-872-0926
Mailing address:
  • Phone: 419-872-2419
  • Fax: 419-872-0926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number954391
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.0006531
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: