Provider Demographics
NPI:1073998795
Name:KLOTZ, LAUREL
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:
Last Name:KLOTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5575 LAKE PARK WAY
Mailing Address - Street 2:STE. 114
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942
Mailing Address - Country:US
Mailing Address - Phone:619-644-7802
Mailing Address - Fax:
Practice Address - Street 1:5575 LAKE PARK WAY
Practice Address - Street 2:STE. 114
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-1664
Practice Address - Country:US
Practice Address - Phone:619-644-7802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-23
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31740106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist