Provider Demographics
NPI:1548582117
Name:KLICKSTEIN-FORMAN, KAREN ANNE (LISW-CP)
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:ANNE
Last Name:KLICKSTEIN-FORMAN
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 PINCKNEY ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-3115
Mailing Address - Country:US
Mailing Address - Phone:843-224-8010
Mailing Address - Fax:843-577-0541
Practice Address - Street 1:32 PINCKNEY ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-3115
Practice Address - Country:US
Practice Address - Phone:843-224-8010
Practice Address - Fax:843-577-0541
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC49311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical