Provider Demographics
NPI:1467532424
Name:KLITZKE, MICHAEL JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:KLITZKE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6025 BROOKVALE LN
Mailing Address - Street 2:SUITE 205
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-4031
Mailing Address - Country:US
Mailing Address - Phone:865-588-7057
Mailing Address - Fax:865-691-3163
Practice Address - Street 1:6025 BROOKVALE LN
Practice Address - Street 2:SUITE 205
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-4031
Practice Address - Country:US
Practice Address - Phone:865-588-7057
Practice Address - Fax:865-691-3163
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1761103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3688000Medicare ID - Type Unspecified