Healthcare Provider Details

I. General information

NPI: 1679872667
Provider Name (Legal Business Name): MS. KARIM CAMILLE KLECKLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. KARIM CAMILLE TARTER

II. Dates (important events)

Enumeration Date: 03/16/2011
Last Update Date: 03/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E WALNUT ST ROOM 200
PASADENA CA
91101-1580
US

IV. Provider business mailing address

595 E CALAVERAS ST
ALTADENA CA
91001-2265
US

V. Phone/Fax

Practice location:
  • Phone: 626-356-5281
  • Fax: 626-356-9416
Mailing address:
  • Phone: 626-356-5281
  • Fax: 626-568-1914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: