Provider Demographics
NPI:1962550236
Name:CLANCY, KRISTIE HUBBARD (LMSW)
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:HUBBARD
Last Name:CLANCY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 ONONDAGA ST
Mailing Address - Street 2:
Mailing Address - City:SKANEATELES
Mailing Address - State:NY
Mailing Address - Zip Code:13152-1336
Mailing Address - Country:US
Mailing Address - Phone:325-685-4702
Mailing Address - Fax:
Practice Address - Street 1:635 JAMES ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2226
Practice Address - Country:US
Practice Address - Phone:315-472-3171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0740991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01649605Medicaid