MEDICARE: MS. VIRGINIA CLANCY LCSW

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	SW21871	FL
2	101YM0800X	Mental Health Counselor	SW21871	FL
3	104100000X	Social Worker	SW21871	FL
4	1041C0700X	Clinical Social Worker	SW21871	FL

General Provider Information

NPI Number	:	1386412096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VIRGINIA CLANCY LCSW

Provider Business Mailing Address
First Line	:	5688 PEBBLE BROOK LN
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33472-2401
Country	:	US
Telephone Number	:	954-740-2530
Fax Number	:

Provider Business Practice Location Address
First Line	:	5688 PEBBLE BROOK LN
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33472-2401
Country	:	US
Telephone Number	:	954-740-2530
Fax Number	:

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

Provider Enumeration Date	:	12/13/2023
Last Update Date	:	12/13/2023

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