Provider Demographics
NPI:1265558506
Name:KLOTZBACK, CATHY WYATT
Entity type:Individual
Prefix:
First Name:CATHY
Middle Name:WYATT
Last Name:KLOTZBACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 COLUMBINE DR
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:KY
Mailing Address - Zip Code:40311-9051
Mailing Address - Country:US
Mailing Address - Phone:859-289-3203
Mailing Address - Fax:859-289-3203
Practice Address - Street 1:200 COLUMBINE DR
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:KY
Practice Address - Zip Code:40311-9051
Practice Address - Country:US
Practice Address - Phone:859-289-3203
Practice Address - Fax:859-289-3203
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY01971171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY01971OtherKY FIRST STEPS PSC CBIS #