Provider Demographics
NPI:1336112093
Name:PAMELA S KLONOFF PHD PLLC
Entity Type:Organization
Organization Name:PAMELA S KLONOFF PHD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:S
Authorized Official - Last Name:KLONOFF
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:602-406-3473
Mailing Address - Street 1:PO BOX 27340
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85061-7340
Mailing Address - Country:US
Mailing Address - Phone:602-943-9200
Mailing Address - Fax:602-216-3000
Practice Address - Street 1:222 W THOMAS RD
Practice Address - Street 2:SUITE 401
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4419
Practice Address - Country:US
Practice Address - Phone:602-406-3473
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-10
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1239103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ731332Medicaid
R09420Medicare UPIN
AZ731332Medicaid