Provider Demographics
NPI:1093990061
Name:VAN KLEECK, PHILLIP EDWARD (MA)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:EDWARD
Last Name:VAN KLEECK
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2523 US HIGHWAY 27 S
Mailing Address - Street 2:SUITE 130
Mailing Address - City:AVON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33825-9690
Mailing Address - Country:US
Mailing Address - Phone:863-991-5209
Mailing Address - Fax:
Practice Address - Street 1:2523 US HIGHWAY 27 S
Practice Address - Street 2:SUITE 130
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825-9690
Practice Address - Country:US
Practice Address - Phone:863-991-5209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 9545101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1093990016Medicaid