Healthcare Provider Details

I. General information

NPI: 1912987058
Provider Name (Legal Business Name): EILEEN KLITSCH PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4734 LONG BEACH RD SE
SOUTHPORT NC
28461-8721
US

IV. Provider business mailing address

4734 LONG BEACH RD SE
SOUTHPORT NC
28461-8721
US

V. Phone/Fax

Practice location:
  • Phone: 910-457-0070
  • Fax: 910-457-0062
Mailing address:
  • Phone: 910-457-0070
  • Fax: 910-457-0062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3068
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: