Provider Demographics
NPI:1538302682
Name:KLICH, EDWARD JAMES (LCSW)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:JAMES
Last Name:KLICH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6035 TUCKERMAN LN
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-1401
Mailing Address - Country:US
Mailing Address - Phone:719-598-4221
Mailing Address - Fax:
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-365-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-18
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1208-LCSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO306953Medicare PIN