Healthcare Provider Details

I. General information

NPI: 1972799690
Provider Name (Legal Business Name): GARY KLOZENBUCHER LSCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2007
Last Update Date: 07/18/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING 7672
FORT RILEY KS
66442-4030
US

IV. Provider business mailing address

650 HUEBNER RD
FORT RILEY KS
66442-4030
US

V. Phone/Fax

Practice location:
  • Phone: 788-240-6189
  • Fax:
Mailing address:
  • Phone: 788-239-7208
  • Fax: 785-239-7364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1571
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: