MEDICARE: BEVERLY CLANCY

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	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1851876858
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEVERLY CLANCY

Provider Business Mailing Address
First Line	:	2005 VALPARAISO ST STE 209
Second Line	:
City	:	VALPARAISO
State	:	IN
Zip	:	46383-3331
Country	:	US
Telephone Number	:	219-252-5464
Fax Number	:	219-728-1860

Provider Business Practice Location Address
First Line	:	601 FRANKLIN ST STE 103
Second Line	:
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-3552
Country	:	US
Telephone Number	:	219-877-4772
Fax Number	:

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

Provider Enumeration Date	:	09/26/2018
Last Update Date	:	09/26/2018

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Directions to “ BEVERLY CLANCY ” Practice Location

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