Healthcare Provider Details

I. General information

NPI: 1750643474
Provider Name (Legal Business Name): MISS OLIVIA KLOTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 06/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 MANCHESTER BOULEVARD 104
INGLEWOOD CA
90301
US

IV. Provider business mailing address

614 MANCHESTER BOULEVARD 104
INGLEWOOD CA
90301
US

V. Phone/Fax

Practice location:
  • Phone: 310-412-0879
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number70222
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: