Provider Demographics
NPI:1073922357
Name:KLATT, VICKI (EDS)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:KLATT
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55707 INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43912-1516
Mailing Address - Country:US
Mailing Address - Phone:740-635-0853
Mailing Address - Fax:740-635-6008
Practice Address - Street 1:55707 INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:OH
Practice Address - Zip Code:43912-1516
Practice Address - Country:US
Practice Address - Phone:740-635-0853
Practice Address - Fax:740-635-6008
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH1313976103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool