Provider Demographics
NPI:1760531966
Name:KLOSS, MICKI M (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICKI
Middle Name:M
Last Name:KLOSS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MICKI
Other - Middle Name:MARILYN
Other - Last Name:KLOSS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8669 EAST SAN ALBERTO
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258
Mailing Address - Country:US
Mailing Address - Phone:480-946-5226
Mailing Address - Fax:480-946-4722
Practice Address - Street 1:8669 EAST SAN ALBERTO
Practice Address - Street 2:SUITE 100
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258
Practice Address - Country:US
Practice Address - Phone:480-946-5226
Practice Address - Fax:480-946-4722
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMFT0157103T00000X
AZ2948116103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
054627OtherVALUE OPTIONS
AZ0607470OtherBCBS
50308OtherCIGNA
5201615OtherAETNA