Provider Demographics
NPI:1205155900
Name:KLEINBAUM, JOHN SAMUEL
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:SAMUEL
Last Name:KLEINBAUM
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:KLEINBAUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:7414 LINDEN LN
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-5129
Mailing Address - Country:US
Mailing Address - Phone:941-356-7221
Mailing Address - Fax:
Practice Address - Street 1:7414 LINDEN LN
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-5129
Practice Address - Country:US
Practice Address - Phone:941-356-7221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-20
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4403103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical