Provider Demographics
NPI:1811287303
Name:MANDY KLEIN LCSW, RPT-S
Entity type:Organization
Organization Name:MANDY KLEIN LCSW, RPT-S
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, RPT-S
Authorized Official - Phone:901-430-5009
Mailing Address - Street 1:3205 KIRBY WHITTEN RD STE 203D
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38134-2853
Mailing Address - Country:US
Mailing Address - Phone:901-430-5009
Mailing Address - Fax:901-284-0527
Practice Address - Street 1:2913 KING ST
Practice Address - Street 2:STE 3
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5322
Practice Address - Country:US
Practice Address - Phone:870-275-7408
Practice Address - Fax:866-591-1451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-18
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2001-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR185952744Medicaid
TNQ044193Medicaid