Provider Demographics
NPI:1356495808
Name:KLOTZBACH, CORA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CORA
Middle Name:
Last Name:KLOTZBACH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 FRONT STREET
Mailing Address - Street 2:SUITE 230
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930
Mailing Address - Country:US
Mailing Address - Phone:307-789-6773
Mailing Address - Fax:307-789-3244
Practice Address - Street 1:724 FRONT STREET
Practice Address - Street 2:SUITE 230
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930
Practice Address - Country:US
Practice Address - Phone:307-789-6773
Practice Address - Fax:307-789-3244
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY302103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY304878Medicare ID - Type Unspecified