MEDICARE: MICHAEL W CLANCY LCPC, LCADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	LCA323	MD
2	101YM0800X	Mental Health Counselor	LC1210	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	647213-01	OTHER	MD	CAREFIRST RENDERING
2	M3280007	OTHER	MD	BC/BS NATL CAP REGION

General Provider Information

NPI Number	:	1346276292
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL W CLANCY LCPC, LCADC

Provider Business Mailing Address
First Line	:	10630 LITTLE PATUXENT PKWY
Second Line	:	SUITE 209
City	:	COLUMBIA
State	:	MD
Zip	:	21044-3264
Country	:	US
Telephone Number	:	410-740-8066
Fax Number	:	410-740-8068

Provider Business Practice Location Address
First Line	:	10630 LITTLE PATUXENT PKWY
Second Line	:	SUITE 209
City	:	COLUMBIA
State	:	MD
Zip	:	21044-3273
Country	:	US
Telephone Number	:	410-740-8066
Fax Number	:	410-740-8068

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	06/17/2014

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Directions to “ MICHAEL W CLANCY LCPC, LCADC” Practice Location

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