Healthcare Provider Details

I. General information

NPI: 1578412532
Provider Name (Legal Business Name): JOSEPH RUSSELL KLIEGEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3192 GLEN CANYON RD
SCOTTS VALLEY CA
95066-4916
US

IV. Provider business mailing address

3600 GLEN CANYON RD
SCOTTS VALLEY CA
95066-4923
US

V. Phone/Fax

Practice location:
  • Phone: 855-933-4897
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRT1431900226
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: