Provider Demographics
NPI:1154484517
Name:KLIM, DOUGLAS (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:
Last Name:KLIM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4190 BELFORT RD STE 140
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-5871
Mailing Address - Country:US
Mailing Address - Phone:904-296-1120
Mailing Address - Fax:904-296-0229
Practice Address - Street 1:4190 BELFORT RD STE 140
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5871
Practice Address - Country:US
Practice Address - Phone:904-296-1120
Practice Address - Fax:904-296-0229
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW47271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE8470Medicare ID - Type Unspecified