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General NPI Number Information
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NPI Number | 1457860884
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Entity Type | Individual
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Provider Name | SAMANTHA LYNN KLOCKOW PSYD, LP
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Gender | Female
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Dates
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Enumeration Date | 09/28/2017
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Last Update Date | 07/22/2025
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Provider Practice Location Address
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Address Line | 4131 W LOOMIS RD APT 120
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City | GREENFIELD
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State | WI
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Zip | 53221-2006
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Country | US
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Telephone | 414-424-2445
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Fax | 414-424-2446
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Provider Business Mailing Address
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Address Line | 1900 SILVER LAKE RD NW STE 110
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City | NEW BRIGHTON
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State | MN
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Zip | 55112-1789
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Country | US
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Telephone | 651-628-9566
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Fax | 651-628-0411
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 6493
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 3983-57
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License Number State | WI
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