Provider Demographics
NPI:1831363126
Name:MICHEAL J KLITZKE
Entity type:Organization
Organization Name:MICHEAL J KLITZKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:KLITZKE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:865-588-6916
Mailing Address - Street 1:6025 BROOKVALE LN
Mailing Address - Street 2:SUITE 205
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-4031
Mailing Address - Country:US
Mailing Address - Phone:865-588-6916
Mailing Address - Fax:
Practice Address - Street 1:6025 BROOKVALE LN
Practice Address - Street 2:SUITE 205
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-4031
Practice Address - Country:US
Practice Address - Phone:865-588-6916
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1761103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3688001Medicaid