Provider Demographics
NPI:1295171817
Name:KLOTZ, IRENE SHANE (LMSW CPT)
Entity type:Individual
Prefix:MS
First Name:IRENE
Middle Name:SHANE
Last Name:KLOTZ
Suffix:
Gender:F
Credentials:LMSW CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3265 JOHNSON AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-3539
Mailing Address - Country:US
Mailing Address - Phone:917-796-4456
Mailing Address - Fax:
Practice Address - Street 1:3265 JOHNSON AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-3539
Practice Address - Country:US
Practice Address - Phone:917-796-4456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049540-1101YP2500X, 103K00000X, 104100000X, 171M00000X, 172V00000X, 174400000X, 174H00000X, 208D00000X, 246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No174400000XOther Service ProvidersSpecialist
No174H00000XOther Service ProvidersHealth Educator
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy