Provider Demographics
NPI:1790328763
Name:DAVID KLIMISCH LPC INC
Entity Type:Organization
Organization Name:DAVID KLIMISCH LPC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:KLIMISCH
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:262-564-5305
Mailing Address - Street 1:6123 GREEN BAY RD STE 240
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2927
Mailing Address - Country:US
Mailing Address - Phone:262-564-5305
Mailing Address - Fax:262-564-5306
Practice Address - Street 1:6123 GREEN BAY RD STE 240
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2927
Practice Address - Country:US
Practice Address - Phone:262-564-5305
Practice Address - Fax:262-564-5306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1427544337Medicaid