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General NPI Number Information
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NPI Number | 1992039804
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Entity Type | Individual
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Provider Name | MS. KRISTA MARIE CLANCY
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Gender | Female
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Dates
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Enumeration Date | 09/24/2009
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Last Update Date | 10/17/2014
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Provider Practice Location Address
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Address Line | 41935 12 MILE RD. CHRILDREN'S HOSPITAL OF MI AUTISM CENTER
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City | NOVI
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State | MI
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Zip | 48377
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Country | US
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Telephone | 248-305-6211
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Fax |
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Provider Business Mailing Address
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Address Line | 4201 ST. ANTOINE UHC 6F MAILBOX# 226 UNIVERSITY PEDIATRICIANS
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City | DETROIT
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State | MI
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Zip | 48201
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Country | US
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Telephone | 313-966-5051
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 6301011361
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License Number State | MI
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