Healthcare Provider Details

I. General information

NPI: 1679872394
Provider Name (Legal Business Name): ELLEN MARGO KLEIN-SOUTH M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2011
Last Update Date: 03/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3881 NE SUGARHILL AVE
JENSEN BEACH FL
34957-3731
US

IV. Provider business mailing address

3881 NE SUGARHILL AVE
JENSEN BEACH FL
34957-3731
US

V. Phone/Fax

Practice location:
  • Phone: 772-334-4035
  • Fax: 772-334-4036
Mailing address:
  • Phone: 772-334-4035
  • Fax: 772-334-4036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSS0000535
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: