Provider Demographics
NPI:1255675112
Name:KLECKER, DEBORAH J (LPC, MFT-IT, SAC-IT)
Entity Type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:J
Last Name:KLECKER
Suffix:
Gender:F
Credentials:LPC, MFT-IT, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W6269 TRAIN RD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3909
Mailing Address - Country:US
Mailing Address - Phone:262-893-7870
Mailing Address - Fax:262-567-7377
Practice Address - Street 1:970 S SILVER LAKE ST
Practice Address - Street 2:SUITE #103
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3802
Practice Address - Country:US
Practice Address - Phone:262-567-7377
Practice Address - Fax:262-567-7377
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2013-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15898-130101YA0400X
WI178-228106H00000X
WI4958-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1255675112Medicaid