Provider Demographics
NPI:1750643474
Name:KLOTZ, OLIVIA
Entity Type:Individual
Prefix:MISS
First Name:OLIVIA
Middle Name:
Last Name:KLOTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 MANCHESTER BOULEVARD
Mailing Address - Street 2:104
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:614 MANCHESTER BOULEVARD
Practice Address - Street 2:104
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301
Practice Address - Country:US
Practice Address - Phone:310-412-0879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70222106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist