Provider Demographics
NPI:1497936926
Name:KLECKER, THOMAS EDWARD (LICSW LP)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:EDWARD
Last Name:KLECKER
Suffix:
Gender:M
Credentials:LICSW LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:NORTHERN PINES MENTAL HEALTH CENTER
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-0367
Mailing Address - Country:US
Mailing Address - Phone:320-632-6647
Mailing Address - Fax:320-632-9525
Practice Address - Street 1:1906 5TH AVE SE
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-0367
Practice Address - Country:US
Practice Address - Phone:320-632-6647
Practice Address - Fax:320-632-9525
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1802103TC1900X
MNLICSW20451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6268607OtherMEDICA
MN69658KLOtherBLUE CROSS