Provider Demographics
NPI:1790778124
Name:KLOPFENSTEIN, THOMAS DAVID (MSW LCSW LCAC)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:DAVID
Last Name:KLOPFENSTEIN
Suffix:
Gender:M
Credentials:MSW LCSW LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N MICHIGAN ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-1770
Mailing Address - Country:US
Mailing Address - Phone:574-935-9449
Mailing Address - Fax:574-935-3956
Practice Address - Street 1:310 N MICHIGAN ST
Practice Address - Street 2:SUITE 208
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-1770
Practice Address - Country:US
Practice Address - Phone:574-935-9449
Practice Address - Fax:574-935-3956
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004597A104100000X
IN87000150A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100114180Medicaid
IN200095080AMedicaid
512560FMedicare ID - Type Unspecified