Provider Demographics
NPI:1790143626
Name:KLETKEWICZ, STAN JR (MA)
Entity Type:Individual
Prefix:MR
First Name:STAN
Middle Name:
Last Name:KLETKEWICZ
Suffix:JR
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1436 HAINESPORT RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-9509
Mailing Address - Country:US
Mailing Address - Phone:856-912-8834
Mailing Address - Fax:
Practice Address - Street 1:66 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-2719
Practice Address - Country:US
Practice Address - Phone:856-912-8834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-06
Last Update Date:2016-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00231700101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional