Provider Demographics
NPI:1689969651
Name:KLOTT, REBECCA A (PHD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:A
Last Name:KLOTT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MONROE AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1455
Mailing Address - Country:US
Mailing Address - Phone:616-259-7207
Mailing Address - Fax:616-259-7261
Practice Address - Street 1:1000 MONROE AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1455
Practice Address - Country:US
Practice Address - Phone:616-259-7207
Practice Address - Fax:616-259-7261
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-17
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015303103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical