Provider Demographics
NPI:1649458191
Name:KLUG, FRED (PHD)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:KLUG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 224
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62263-0224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 S GRAND ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:IL
Practice Address - Zip Code:62263-1534
Practice Address - Country:US
Practice Address - Phone:618-327-8236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical