Provider Demographics
NPI:1265860175
Name:KLOCK, MEGAN (MS, LPC)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:KLOCK
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 S MARR ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4334
Mailing Address - Country:US
Mailing Address - Phone:920-926-4207
Mailing Address - Fax:920-926-8875
Practice Address - Street 1:21 S MARR ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4334
Practice Address - Country:US
Practice Address - Phone:920-926-4207
Practice Address - Fax:920-926-8875
Is Sole Proprietor?:No
Enumeration Date:2013-10-31
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6775-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional