Provider Demographics
NPI:1649412743
Name:KLINCK, BRIAN PAUL (PSYD)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:PAUL
Last Name:KLINCK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 E BELL RD
Mailing Address - Street 2:#2400
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032
Mailing Address - Country:US
Mailing Address - Phone:623-322-5700
Mailing Address - Fax:623-337-5305
Practice Address - Street 1:13640 N 99TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351
Practice Address - Country:US
Practice Address - Phone:623-322-5700
Practice Address - Fax:623-337-5305
Is Sole Proprietor?:No
Enumeration Date:2009-04-03
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4039103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ441623Medicaid
AZ441623Medicaid
AZZ131154Medicare PIN