Healthcare Provider Details

I. General information

NPI: 1790778124
Provider Name (Legal Business Name): THOMAS DAVID KLOPFENSTEIN MSW LCSW LCAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 01/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 N MICHIGAN ST SUITE 208
PLYMOUTH IN
46563-1770
US

IV. Provider business mailing address

310 N MICHIGAN ST SUITE 208
PLYMOUTH IN
46563-1770
US

V. Phone/Fax

Practice location:
  • Phone: 574-935-9449
  • Fax: 574-935-3956
Mailing address:
  • Phone: 574-935-9449
  • Fax: 574-935-3956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number34004597A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number87000150A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: