Healthcare Provider Details

I. General information

NPI: 1679351043
Provider Name (Legal Business Name): RICHARD TEMPLE KLEIN III EDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 N FEDERAL HWY STE 370
BOCA RATON FL
33487-4910
US

IV. Provider business mailing address

1640 NE 5TH ST
FORT LAUDERDALE FL
33301-1324
US

V. Phone/Fax

Practice location:
  • Phone: 561-203-9812
  • Fax:
Mailing address:
  • Phone: 773-490-9301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSS1756
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: