Basic Information
Provider Information | |||||||||
NPI: | 1629280250 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLANCY | ||||||||
FirstName: | SEREN | ||||||||
MiddleName: | MORRIS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCPC, LPCC, LPAT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MORRIS | ||||||||
OtherFirstName: | LINNEA | ||||||||
OtherMiddleName: | SERENDEE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1423 W FRANKLIN ST | ||||||||
Address2: |   | ||||||||
City: | BOISE | ||||||||
State: | ID | ||||||||
PostalCode: | 837025024 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083452212 | ||||||||
FaxNumber: | 2083452282 | ||||||||
Practice Location | |||||||||
Address1: | 1423 W FRANKLIN ST | ||||||||
Address2: |   | ||||||||
City: | BOISE | ||||||||
State: | ID | ||||||||
PostalCode: | 837025024 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083452212 | ||||||||
FaxNumber: | 2083452282 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2007 | ||||||||
LastUpdateDate: | 05/20/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LCPC-5108 | ID | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 0122221 | NM | N |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.