Provider Demographics
NPI:1821378126
Name:KLOTER, RUSSELL T (LADC)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:T
Last Name:KLOTER
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 ELM ST
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-3240
Mailing Address - Country:US
Mailing Address - Phone:860-875-0292
Mailing Address - Fax:860-871-4910
Practice Address - Street 1:60 ELM ST
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-3240
Practice Address - Country:US
Practice Address - Phone:860-875-0292
Practice Address - Fax:860-871-4910
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000784101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)