Provider Demographics
NPI:1770362113
Name:KLOSE, DONALD ATWOOD
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:ATWOOD
Last Name:KLOSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 BAYSIDE CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-7460
Mailing Address - Country:US
Mailing Address - Phone:510-697-5307
Mailing Address - Fax:
Practice Address - Street 1:191 BAYSIDE CT
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-7460
Practice Address - Country:US
Practice Address - Phone:510-697-5307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15939106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist