Provider Demographics
NPI:1558402701
Name:KLINGEL, MARY JO (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY JO
Middle Name:
Last Name:KLINGEL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6612 E WT HARRIS BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-5135
Mailing Address - Country:US
Mailing Address - Phone:704-241-6520
Mailing Address - Fax:
Practice Address - Street 1:6612 E WT HARRIS BLVD STE D
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215
Practice Address - Country:US
Practice Address - Phone:704-241-6520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0109891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ1230OtherBLUE CROSS BLUE SHIELD