Provider Demographics
NPI:1093165995
Name:KLAKUS, KATHARINA
Entity Type:Individual
Prefix:
First Name:KATHARINA
Middle Name:
Last Name:KLAKUS
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 1:457 COVENTRY LN STE 115
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7571
Mailing Address - Country:US
Mailing Address - Phone:312-584-6739
Mailing Address - Fax:
Practice Address - Street 1:457 COVENTRY LN STE 116
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7571
Practice Address - Country:US
Practice Address - Phone:312-584-6739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2023-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY31066103T00000X
101Y00000X, 390200000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program