MEDICARE: EILEEN KLITSCH PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	3068	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	046UA	OTHER	NC	BCBSNC

General Provider Information

NPI Number	:	1912987058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EILEEN KLITSCH PHD

Provider Business Mailing Address
First Line	:	4734 LONG BEACH RD SE
Second Line	:
City	:	SOUTHPORT
State	:	NC
Zip	:	28461-8721
Country	:	US
Telephone Number	:	910-457-0070
Fax Number	:	910-457-0062

Provider Business Practice Location Address
First Line	:	4734 LONG BEACH RD SE
Second Line	:
City	:	SOUTHPORT
State	:	NC
Zip	:	28461-8721
Country	:	US
Telephone Number	:	910-457-0070
Fax Number	:	910-457-0062

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/17/2006
Last Update Date	:	07/08/2007

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Directions to “ EILEEN KLITSCH PHD” Practice Location

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