Healthcare Provider Details

I. General information

NPI: 1700949450
Provider Name (Legal Business Name): CAROLL S KLING LPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2006
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2178 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4535
US

IV. Provider business mailing address

2178 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4535
US

V. Phone/Fax

Practice location:
  • Phone: 805-781-4711
  • Fax:
Mailing address:
  • Phone: 805-781-4711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT30771
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: